The “There’s One More Thing” Exam

By Russell Herring, DNP, FNP-BC, CSCS

It always comes as, “there’s one more thing”. It’s almost always the real reason for the appointment.

“Wait, there’s one more thing…”

We’ve been talking for many minutes, I’m reviewing my findings, actions and conclusions with the patient and may even be standing up with my stethoscope and pen.

“There’s one more thing…”

“There’s one more thing” is virtually guaranteed to be complicated, medically, emotionally, personally or sometimes legally. Like a conversation with a stranger on a very long flight, there are things you start with, the lead-in. We talk about the weather. We talk about the news. We talk about anything other than the things which matter most. Sometimes these are social norms, sometimes we’re shy or embarrassed.

In the exam room, “one more thing” is rarely something we’ve never heard before. Even a poor statistician will correctly remind us that there are outliers, there are instances which are truly unique and inexplicable in nearly all things, but your “one more thing” probably isn’t it.

One more thing” is often something that should have been addressed a while ago. Days, weeks, months – years, even… “One more thing” is often that thing which had to get bad enough, or hang around long enough, that you finally couldn’t ignore it any longer. “One more thing” is rarely physically painful, unless it started as something which could be embarrassing or socially painful, allowed to fester into something physically painful.

These things happen.

I’ve learned to provide an opening for “one more thing”. I’ll review what we’ve discussed, what I’ve written down, our next steps… “We’re increasing your blood pressure medicine, and radiology will be calling to schedule your mammogram. You’re going to work on your diet and we’ll check your cholesterol again in 6 months.” I’ll look the patient in the eyes and ask, “did we talk about everything we needed to? Is there anything else we need to cover? Threats, comments, accusations?” One. More. Thing?

The patient will suddenly find somewhere on the floor to fix their gaze.

In the exam room, we’ve heard “one more thing” many, many times before. We’re poker players. Like a priest in confessional, we’re adept at sitting across the table, stone-faced. The patient may roll up a sleeve or a pant leg. “One more thing” has ended with me inspecting a patient’s nether bits, once while a family member pulled out a smart phone to show me the pictures they’d taken earlier.

I love technology.

I suppose my message here, like a parent on the first day of school, is to tell you not to be shy. If your “one more thing” bothers you, then we want to hear about it. We want to set your mind at ease, to resolve the problem, whatever that means. Really, my only problem with “one more thing” is that it almost always occurs when we’re nearly out of time. It is human nature and there isn’t much I can do about it, other than to say don’t be shy, we won’t bite. Just like a parent at school, “don’t be shy, they won’t bite you. Go ahead, say hello”. “One more thing” happens at the very end of an exam because it takes the pressure off of what happens next.

“I was abducted by Bigfoot and taken to his spaceship, where he gave me the sacred riddle of steel, and now I can only eat avocados,” leaves a bit of a pregnant pause in conversation, and it seems as though people prefer to drop it right at the finish line, rather than leading with it and then spending another 55 minutes in a room with someone they just met. It can be challenging to talk about flu shots after a lead-in involving Bigfoot, but I assure you we can do it, and I’d personally prefer it that way.

Tell me about the spaceship ride. Tell me about your erratic sleep habits. You aren’t the only person who’s found a lump in that spot.

I’ve had to step out of the exam room and tell my nurse that I’m going to be longer with a patient and not to rush the next person into the other exam room.

“I’m going to need extra time.”

Wherever you are out there, whatever you’ve been pushing around in the back of your mind, worried what a doctor is going to say when you tell them about your particular, “one more thing”, come in. Tell us. Please. Your healthcare provider is there to help. We want to.

We’re experienced with “one more thing”.

I’ve treated five cases already this week.

Russell Herring
Russell Herring, DNP

About Russell Herring, DNP, FNP-BC, CSCS

Russell R. Herring, DNP, joined the Great Falls Clinic in 2018 and is among the newer healthcare providers and prescribers in the State of Montana. He works alongside Dr. David Engbrecht and Dr. Carey Welsh in Family Medicine at the Great Falls Clinic Northwest location. Russell specializes in diagnostic, preventive, and therapeutic healthcare and treatment plans for acute and chronic illness, and in education and guidance of patients regarding disease prevention and health promotion. He is currently accepting new patients at the Northwest Clinic, 1600 Division Road, Great Falls. For more information or to schedule an appointment, please call 406-268-1600.