How are you today?

"Oh, I'm fine..."
[Allegorical Portrait of Elizabeth I via wikimedia]

One of the questions that makes me cringe is frequently the very first question asked in an SP encounter. The student doctor walks into the room, smiles, and says, "How are you today?"

I cringe because as a patient, I have two choices:

1. "Fine." Which is totally not true, because why would I have come to the doctor if I was fine? But as a patient, I know this is the only socially acceptable answer and the one the doctor is expecting to hear. So I assume the student doctor values social courtesies more than the truth, which makes me feel anxious. I may also assume the doctor is not sensitive, empathic or present.

2. Tell something closer to the truth: "Well, not so great. That's why I'm here." A student doctor's response to this will tell me a lot about how safe I will feel for the rest of the encounter. In many cases, this mild challenge really throws them for a loop and the reaction is almost defensive. A better student doctor will acknowledge the bind of that question, which will leave me feeling relieved and safer to challenge the doctor if the need arises again.

"How are you?" is a habitual phrase that is completely unnecessary to communicate rapport or respect. In fact, because of the power differential, it does more harm than good by requiring patients to either lie  to seem like a "good" patient, or to challenge the doctor and deal with the possible stigma of being a difficult patient.

The first few minutes of any encounter are crucial to setting a sense of safety and honesty. Asking questions that only have one acceptable answer trains patients to lie. In this case, a small lie, to be sure. But lies of any kind undermine a patient's trust and may lead to self-censure.

A better opening: A proper introduction followed by either "What brings you in today?" or "I see you're here for X. I'm sorry to hear that. Can you tell me more about what's going on?"