Saturday, January 27, 2007

A Common Entity

How many times have you experienced this?
The waiting room is full and a patient comes in, settles down comfortably and says, "I won't take up much of your time today, I see how busy you are. So I wrote down a few questions." Thus spake a healthy 55 year old man as he sat down and pulled out this post-it from his pocket. "La Maladie du Petit Papier," I thought with resignation.

PubMed has only five references to this entity we all know. The first in Italian from 1967. * We each have our own way of handling this. Some docs grab the list from the patient and say, ""Let's have a look at this." Others say, we'll deal with only three today; you choose." I usually let them read all of them and then proceed.

How do you handle this event? A couple of years ago there was a piece in the BMJ comparing the malady of the petit papier with the newly emerging la maladie du grand printout. The latter may be more common in the major cities of North America than elsewhere.

* Iandolo C. [The "petit papier" sign] [Article in Italian]
Policlinico [Prat]. 1967 Mar 6;74(10):321-8.


  1. In 28 years of pediatric practice, I can testify that “La Maladie du Petit Papier” is alive and well. Knowledge that the parent of the patient whom you are about to see harbors such a list is guaranteed to produce a queasy feeling in the stomach, considering that the discussion is likely to go on ad nauseum until the visit is concluded.

    In our practice, medical assistants process patients, jotting down vital signs, the chief complaint, and brief historical salient points before escorting them to an examination room. If they see that the parent is wielding a small scrap of paper bearing a list of questions, many times the medical assistant will merely record the phrase: “has list” under the chief complaint.

    This can be a real problem in a high-volume pediatric practice, where sick patients are scheduled every 10 minutes in between well-baby exams, which are allotted a generous 15 minutes of time.

    To make matters worse, many times the questions consist of general topics that require the equivalent of an extemporaneous doctoral dissertation to answer—What should she be feeding; how much and how often? She spits up all the time after she drinks her bottle; is that normal? She stools once a day; is that sufficient? What about the color of the stool (hers are green)? She can sit up now; what else should she be doing developmentally? She gets diaper rash all the time; am I doing something wrong? What’s the best way to treat it? How should I dress her in the winter time when it’s so cold outside? How should I dress her in the summer when it’s so hot? How can I stop her from sucking her thumb? Is it OK for her to suck her thumb?

    And then comes the final, all-encompassing, sixty-five thousand dollar question: “Is there anything else I need to worry about?”

    To which I am always tempted to respond: “Yes. Tell your psychiatrist that you need to go back on medication for your O.C.D.”

  2. Fortunately I only get a few such cases per week. After a quick internalized scream & hair pulling, I make it a point to take control of the list and go thru it as quickly as I can.


  3. AnonymousJune 26, 2008

    Perhaps if patient's lists bother you, then you should get other jobs. Many chronic deseases have multiple symptoms, so a list can be helpful in excluding anything serious and saving your necks. Parents know their babies/children best, not the doctors. All doctors have is an element of control over which way their worries fall.
    Yes, deal with some symptoms at a later date; ie the moles, but also consider the time you will waste long term by ignoring the list short term.
    It's a sad state of affairs when doctors hold patients or their carers with an element of contempt. You are there primarly to serve others. It's in service to others you will ultimately be rewarded.


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