Saturday, 28 June 2014

It never hurts to let patients second guess you

In training, we learn to ask patients all kinds of questions. But no one taught me to ask what may be the most important question of all: "What do you think is wrong?" I've found that even if the patient's answer isn't on target, it helps me address his concerns. And sometimes when I'm puzzled, the patient actually makes the correct diagnosis. Consider these cases:

Stabbing in the dark for answers

Over a three-month period I saw a 66-year-old woman four times. Her problem was pain in her left knee, but only at night. I could find little if any sign of arthritis, and everything else was normal, including blood tests and X-rays of her knee and hip.

Neither analgesia nor physical therapy helped. I considered depression or a family problem, but there was no evidence of either.

I was stumped. So I asked, "What do you think is wrong?" Without an eye-blink's hesitation, she responded, "I think I have cancer."

"Why would you think that?" I asked.

"I read in a magazine," she explained, "that pain that gets worse at night is often cancer-and it's often missed by doctors."

I was able to reassure her that she didn't have cancer, and she was visibly relieved. The pain resolved spontaneously over the next few weeks. I encouraged her to ask us immediately about anything in her magazine reading that distressed her. (I never did find the article in question. I certainly hope it didn't say what she said it did.)

Reading that paid off

I'd seen a middle-aged woman several times over the years for peptic-ulcer disease. She'd responded well each time, and I talked to her repeatedly about avoiding ulcerogenic substances. I had even drawn a gastrin level on her, which turned out normal. She was getting along reasonably well on [H.sub.2] blockers, but now she was back with what seemed to be a flare-up of the old problem. Discouraged, I broached with her the possibility of undertaking ulcer surgery.

She frowned. I frowned. Neither of us was happy with having to resort to such a procedure.

"Do you have any idea of what else might be wrong?" I asked.

"Well, I'm no doctor," she said shy. "But may I have hyperparathyroidism."

Hyperparathyroidism? Most of my patients stumble over medical terms with half as many syllables. I was surprised that she'd come up with a diagnosis so esoteric. But guess what" Although her serum calcium was in the high-normal range, it turned out she was right. She was a well-educated person who'd come across the disease in her reading, and-unlike the woman with night pain-had been able to steer me in the right direction. She responded well to parathyroid surgery; what's more, she's had no more ulcers.

Spotting a rocky diagnosis

A 51-year-old man came to see me with a rash. It was clearly fungal, and I wrote out an Rx that I said would resolve it within a couple of weeks or so. Two days later he called: The rash was worse. I encouraged him to give the cream more time. Several days later, he insisted on an appointment because he felt the rash wasn't getting better.

In fact, though, it was healing up nicely. Clearly he had something else on his mind, so I asked, "What do you think the problems is.?"

His answer took me by surprise: "I think I have Rocky Mountain spotted fever."

I asked him why he thought that. "Well," he said, "I grew up in the Rockies, and I've got spots. I guess I'm in real trouble." I listed the reasons he didn't have to worry about that illness. I told him again that the rash was fungal, explained once more what had caused it, and assured him that it would resolve. He calmed down considerably, and the rash cleared over the next two weeks.

Itching to live down guilt

I'll never forget the 83-year-old woman with a severe vaginal itch with no findings except for excoriations caused by her own persistent scratching. All tests were normal, all treatment was ineffective, and she was increasingly tearful and anxious. We both felt terrible.

Because I really don't know what to do next, I asked her what she thought was wrong. She knew exactly, and tearfully told me all about it:

"Soon it will be my 6oth wedding anniversary, and my family is having a big party for us. But I don't deserve it! I had sexual relations with a man before my marriage, and now GOD is punishing me with a sinner's disease. Everyone will find out!"

I tested her for CG and syphilis and presented her with copies of the negative results. We talked for a long while about childhood mistakes and how we had the rest of our lives to make up for them. I assured her that she had done just that-and more-by being a good wife, mother, and member of the community. Then I recommended warm baths each night, followed by a new cream. Over the next few weeks, the itching resolved, the excoriations healed, and her mood improved. Her anniversary party, I hear, turned out to be a joyous event.

Making a rash diagnosis

One way or another, it's always helpful to know what happened to members of the patient's family. Recently, for example, a patient I'd been following for years showed up complaining of chest pain. He'd had bypass surgery four years earlier, and had been doing fine. As part of my exam, I did an ECG, and still nothing seemed to explain the pain he was experiencing now.

The I recalled having heard something about the untimely death of his 39-year-old son. "Yes, he died a month ago-he had a heart attack," my patient said, sobbing. That told me what I needed to know to gently steer the conversation to the anxieties he had been burned with.

A large part of my practice is geriatrics, and that means a lot of funny little aches and pains. Many things start out with funny little aches and pains, and their initial similarity can make them hard to nip in the bud.

One of my older patients suffers from chronic back pain, and one day it was worse than usual. She insisted on being seen that afternoon. My front-office assistant agreed to squeeze her in between appointments, and when she arrived I put on my osteoarthritis hat for her. I prescribed treatment as though her musculoskeletal problem was acting up.

She seemed to be relatively comfortable with my conclusions, but as she was standing up to leave, she turned suddenly and asked, "So you don't agree with my diagnosis?"

"What's that?" I exclaimed.

"Two years ago, you treated my sister for shingles, and this is exactly the way hers started."

It was plausible, but there was no rash yet. If it was shingles, the rash might not show up until Day Three, and this was only Day One. I sent her home with office samples of a herpes zoster medication, and told her to start it if the rash developed. And that's exactly what happened. Her intuition--and my willingness to listen-had spared her a return trip to my office and perhaps a delay in tackling the real problem.

One Friday afternoon five years ago, just as we were about to close the office for the weekend, another woman called me about her 18-year-old son's abdominal pains. Could we wait for her? She was certain it was appendicitis.

It was indeed, and we had him in the OR within an hour. "Why did you think it was appendicitis?" I asked her as the surgeon took over. "I saw a case just like this on a TV show," she said.

I remember that conversation vividly, not only because she was so definite about the problem, but also because she was right on the money. Postscript: The son is now a regular patient of mine.

Yes, I know-sometimes you'll startle or confuse the patient if you ask what's wrong. You may get, "You tell me. You're the doctor." But along with all those great questions we learned in medical school, try adding my question for a change. I bet you'll be surprised, educated, or at least amused by the responses you get.

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