“When did it start?” A question I’ve been asked by doctors more times than I care to remember. Ever since I became interested in medicine, I have not understood this question. Somehow, it doesn’t matter how I feel, how bad it is, what it means to me. The crucial bit, asked immediately after I say what I came with, is when it started. It just might be the most irritating question doctors can ask (me).
I was reminded of this question writing the previous post, and reading Jonathon Tomlinson’s blog. Dr Tomlinson quotes a conversation with his patient. The question ‘When did it start?’ appears right at the beginning of the exchange.
Timeline seems to be important this is precisely what this post is about. So, let me start with my own, a patient’s, account of the timeline. Here are my preferred responses to the question when something started:
- Do you monitor yourself?
- I have no (bloody) idea.
- How the f….should I know?
This is on an ascending scale of being pissed off. For whenever I am asked this question, I always find it difficult to answer. Yes, in the case of dramatic events, maybe, I would remember, in the case of more mundane ‘symptoms’, how am I supposed to know when it started? Whether surprisingly or not, I do not take notes recording the minutiae of my life, so that I can access them whenever a GP demands an answer.
Moreover, what kind of accuracy do you expect? Is ‘Last week’ enough, or would you prefer ‘Last Monday’? Or maybe Monday afternoon would be best? When you ask me, finally, when it started, do you mean the fully developed ‘symptoms’ (but, please, let’s not talk about symptoms) or perhaps when I felt that ‘something was wrong’. Or do you mean something yet different that I simply have no idea what you mean? Indeed, dear doctor, you might assume that I know what you mean, but I actually do not!
Such questions assume that we, patients, have a(n in-built) monitoring system that enables us to access the beginning of our ‘symptoms’ and report it. It’s almost like accessing files on our hard disks. You type the command and our, shall I say, lived computers provide you with the data. Well, I‘m afraid it doesn’t work like this.
But there is more to time in medical interviews. In a recent study Justyna Ziolkowska explored ways in which doctors focused on time and timelines. Interestingly, she argued that references to time were used by psychiatrists in order to justify/objectivise their findings. And so, while they focused on timelines when taking medical history (bloody hell, how am I supposed remember what happened a year or two years ago?!), on the other hand, despite that diagnostic criteria required establishing a timeline (e.g. in depression), doctors made ambivalent references to time.
I think Ziolkowska’s point is well made. I see the question ‘when did it start?’ as a means of establishing the ‘hard facts’, however ‘soft’ they are. On the other hand, keeping the timeline fuzzy makes the diagnosis possible and unchallenged. The doctors’ questions are aimed at making the patients’ answers more objective, which is a point Ziolkowska makes in another study. Questions such as ‘When did it start?’ seem to be needed by you, doctor, not by me. And when I say ‘by you’, I do not mean by you so that you can help me. I mean by you so that you can help yourself.
And so I end with a plea. I understand and appreciate that you might want to ask when ‘it started’. But before you do, can you please (pretty please?) make sure that the question is intended, like, truly intended, to help me. I would appreciate it very much.