Falling farther from just what we are

I like asking patients about their jobs. Sometimes it may seem relevant to the complaint. Other times, it could potentially help the therapeutic bond. Mostly, it's just interesting.

Occasionally, I'll hear a patient is not working; that he or she is on disability.

This can surprise me, especially when the patient's interview responses and examination seem quite appropriate and unremarkable.

Now, I'm not in an ED where this happens too often (or maybe I don't ask enough). At any rate, I haven't been compelled to blog about this phenomenon, like, for example, Edwin Leap recently did. And I'm certainly not of the mind that disability payments are responsible for the debt crisis, or that the vast majority of folks on disability don't deserve it.

But I was recall my training in smoking cessation counseling; we were taught that every time a doctor elicits a smoking history but doesn't discourage the practice, a patient takes notice. Maybe the patient doesn't walk away thinking, "my smoking habit is healthy," but perhaps he or she ends up concluding it can't be such a big deal, if the doctor didn't dwell on it.

As a consequence of this training (and the research that backs it up) I do tend to dwell on smoking history. I have all kinds of statistical and anecdotal pearls to trot out, depending on the situation (wound healing, viral URI, heart disease, etc).

I wonder if the same thinking can be applied to those unexpectedly disabled that I see every now and then. Is there a phrase a physician can ask, that expresses some surprise at the incongruence of their presentation and disability status, without coming across as confrontational, or opening up a can of worms?

Perhaps it's just a variation of my formulation, a few paragraphs back: "You're on disability? That's surprising to me; you seem so capable."

And then, just listen.