The Flaw in Our Plan

April 8, 2009

When I was in medical school one of my very first teachers shared with us one of his "pearls." He said, "Very often the history provided by the patient is all you need to make a diagnosis."

When I was in medical school one of my very first teachers shared with us one of his “pearls.” He said, “Very often the history provided by the patient is all you need to make a diagnosis.” I took this to heart, and for the most part I agreed with his assessment. However I have come to realize that the Macbeth version of this, where half-truths make up a large part of the history, is quite different and can lead to all sorts of mischief and misdeeds.

Take my patient two weeks ago. Classic setting: poorly controlled diabetic patient, who takes his insulin about 50% of the time and does not follow any dietary recommendations at all, instead he makes regular fast food take-out runs for burgers and colas. He already has microvascular complications. During a recent visit to my clinic for sudden worsening in his glycemic control (brought about by forgetting another 25% of his insulin doses), he happened to mention (“by the way doc”) about his chest pain last week. “Hmm, did this chest pain happen to start at the same time your glucoses became worse?” “In fact, yes.” “Do you have it now?” “No.” “Has anything else changed during the past week?” “No.”

I quickly came up with a plan after discussing this with a colleague whose husband works in cardiology. I sent this patient to the EKG lab, where he was then to return to me with the EKG. If normal, he could go home and follow up with the cardiologists in clinic. If any changes from his prior EKG, then he was off to the ER. He was very reluctant to go through with this plan; I had to practically beg him to have the EKG done. While in a room with my next patient I was pulled out by my nurse looking somewhat stressed. EKG lab was on the phone.

“We sent your patient to the hospital, he started having chest pain here in EKG lab and his EKG read acute MI.”

Good grief.

But wait, it gets worse.

After several hours of anxiety, hoping my patient was okay and not actively infracting as I wrote notes in clinic, I got my answer while following up on his labs. No cardiac enzymes in the computer, but a tox screen. Positive for cocaine.

Good grief.

So my question is this: how flawed is this system where a patient-provided medical history forms the foundation of our basis for making diagnoses? I would say horribly flawed, but there are not many other ways to obtain such information.

Over time I have learned some ways to find underlying truths. Someone with “10 out of 10 pain,” but comfortably watching TV in the waiting room with a normal pulse rate is likely not truly be in that much pain. Other times you almost need to assume patients are not telling the whole truth in order to not miss a diagnosis: every doctor knows that a female of childbearing age claiming not to be sexually active is to be honorably ignored and subjected to a pregnancy test anyway if she comes to an ER complaining of abdominal pain. There is a great scene in a recent movie where the doctor asks a man having chest pain about using Viagra. The man denies it after which the doctor tells him it’s a good thing since the NTG going through his IV would then kill him. The man then proceeds to rip the IV out of his arm…

Perhaps the fault lies with me. I like to think I am approachable and non-judgmental, but maybe my patients are not quite that comfy with me as yet, so they feel the need to withhold some information? Maybe, maybe not. Some information is clearly very sensitive and not to be shared without utmost trust. I certainly understand this. But the very fact that you are entrusting your health to someone implies a certain level of mutual respect, does it not?

Therefore, I do call this a flaw in the great plan. Humans will be humans, and when embarrassed, wary, or guarded, humans will hide information. It is our jobs to continue to encourage our patents to be completely truthful and upfront with us because our decisions are affected by their information. We NEED their truths in order to do our best jobs. So let me know how much insulin you missed, or the Viagra you take, or that you switched your synthoid for thyroid extract from the anti-aging guru down the street. I won’t judge you. It will help me be a better doctor in future, I promise.