What is it not.

After a quick greeting the young man sat down in the chair adjacent to my desk in my consulting room, after a few minutes of conversation he cut to the chase.

“I’ve got OCD and its driving me mad, I need to stop checking the door is closed, I can’t leave the house without checking the lock again and again…….”

“What is it not” is a question I never really used to ask, I never got taught to ask it, neither is it in the books I had read on consultation skills, the fact is ‘what is it not’ is one of the most important questions you can ever ask.

As a General Practitioner I see patients every day, and my hope is that by asking a few questions, and an examination, I can figure out what’s going on, have a clear diagnosis in mind, and with this work out how to help that person with their condition.

Just like life a medical consultation doesn’t always go to plan, there are times every day that I can’t really put an exact name on the condition the patient presents with, there are times when there is a degree of uncertainty and unknown, and in times like this ‘what is it not’ then becomes the next most important question you can ask.

Seeing the consultation from the patients point of view, they usually have a pretty solid idea what is wrong with them before they have even made the appointment, for them ‘what is it not’ is at times their primary agenda.

Imagine having a cough you may know you have a chest infection, but what you really want is reassurance that it’s not pneumonia, or it’s not lung cancer.

The diagnostic process in hospitals often follow the ‘what is it not pathway’ when a patient is admitted to hospital tests are performed on the patient to work out the diagnosis, but what really happens when things don’t exactly fit is exclusion medicine takes over, we (meaning us as clinicians) run multiple tests to find out ‘what it is not’ before we are left with the most likely diagnosis.

“What is it not is sometime all you need to know to safely send the patient home with advice and reassurance, and sometimes what is it not is all the patient needs to know to go home feeling reassured”.

A physician’s training is focussed on asking questions to find specifically what something is, but these questions never really focus on what something isn’t. However when uncertainty raises its ugly head we also need to focus on the ‘what is it not’ to stay safe, and the quickest way to do this is simply to ask it.

“What is it not?”

The question ‘what is it not’ can cut straight to the hidden agenda, and at times it can also let the patient open up and tell you what they are most worried about.

After we have asked ‘what is it not’ we can also find out what we need to reassure the patient by asking,

“What do you (/we) need to know to know that?”


This need to write this article came to me whilst driving home from an ENT clinic after organising a bundle of MRI scans for patients who had seen me with unilateral tinnitus or hearing loss, the scan was to confirm that ‘it was not’ an acoustic neuroma which is exactly what the scan did in roughly 49 out of 50 scans.

Now lets get back to the story of the young man;

“I’ve got OCD and its driving me mad, I need to stop checking the door is closed, I can’t leave the house without checking the lock again and again…….”

“So what is it not, the door I mean, when you are checking it”
“It’s not open” said the young man.
“What is it you need to know to know that?”
“That is to know, that the door is not open” I added.
“I don’t know he said”

After a little coaching before he left, every day for the next two weeks he stood at the door and finally worked out what he needed to know to know that the door wasn’t open. (By doing this he broke his old pattern, by doing this for 2 weeks he installed a better strategy).    

Next time you have a problem where there is a degree of uncertainty, and especially if you don’t know what the answer is, perhaps the next best thing you can ask is ‘what is it not’.