Wednesday, October 22, 2014

Wisdom Wednesday: The Patient Always Knows

I frequently reiterate this statement to my patients, “on some level, the patient always knows.” As a physician it is my obligation to listen to what my patient is trying to tell me.

Many years ago, during an initial consult, I had a new patient who confided to me, “I don’t know what it is, but I just feel like something is living inside of me.” Initially, I discounted her statement. I continued the history learning that she and her husband had been separated for six months and that her stress levels were quite high.

I ordered some routine lab work on her and scheduled a follow up visit. The lab work include a urine analysis which came back showing Chlamydia, an STD (sexually transmitted disease). Typically, Chlamydia doesn’t show on a UA but will on a vaginal smear. However, her infestation was so high that hundreds of thousands of these microscopic organisms spilled over into the urine. I was very fortunate to have stumbled across the correct diagnosis. Chlamydia looks like sperm, with a head and a tail swimming about. They are too small to feel yet she knew on some level, “something was living inside” of her. When I shared my findings with her she admitted that she had separated from her husband because he had a thing for prostitutes.

Patients live in their bodies 24/7. They know on some level what is going on. However, they often cannot express that information in a way that the physician will understand. Many times, the patient doesn’t really understand what they are trying to say either. That new patient taught me “the patient always knows.”

Medical history is said to account for 75% of an accurate diagnosis. Just watch a couple of episodes of “House” and you will get the idea. However, health care is not really like that anymore. Confirmatory tests are no longer based on a history and exam as traditionally taught. Today, batteries of screening tests are run and the test results give the diagnosis.

Mayo Clinic claims to be the best diagnostic facility in the world. They routinely follow former patient’s health history until death, then perform autopsies to determine if they were indeed correct in their early diagnosis. Statistically, they are right about a third of the time. That is, they are wrong a vast majority of the time and are purported to be the best. Where does that leave the rest of us?

I believe that the health care professions have forgotten the importance of a good history. More than that, we have to really listen to that patient because the patient always knows.

Several years ago, I rushed my younger brother to the hospital with angina that began a couple of hours after a cardiac stress test that he passed with flying colors. The nurse, taking his history in the emergency room, asked him if his pain was sharp or dull. My brother responded “it’s not really sharp or dull, neither word really describes my pain.” The nurse recorded “sharp chest pain”. Later that night, when the cardiologist and I spoke, he assured me that there was no heart issue. After all, he just passed his stress test and his chest pain was sharp, not dull as patient’s generally claim when having angina. I was unconvinced and insisted on a cardiac cauterization which showed a 90% blockage and resulted in a cardiac stint. There was too much dependence on the testing and a poor record of an incomplete history.

Virtually every day a patient will say something to me, out of the blue with no obvious connection to the conversation at hand. Typically, those unsolicited statements are vital pieces of history. Sometimes they translate in a very literal sense, but often they are just clues that a good detective (physician) needs to follow.

Find a primary health care provider that will really listen to you. History really is 75% of an accurate diagnosis.

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