The Patient Was…

Whatever the origin of the idiom “The devil is in the details,” the phrase is applicable in so many spheres of life.

And medicine is no exception.

In clinical medicine, that is, the actual care of patients, the narrative they tell will often lead to the correct diagnosis. One major problem, however, is that patients rarely get the opportunity to fully relate their story. Studies have shown that physicians often interrupt patients within 11 to 23 seconds of their beginning to describe their complaint or tell the history of their illness. That’s 11 to 23 seconds!

The reasons for this almost unbelievable phenomenon are many. Time constraints, an urge for efficiency in the medical practice, an exaggerated sense of knowledge and self-importance, simple habit, and a desire to fit a patient’s narrative into a pre-conceived category, are all potential causes for this phenomenon of narrative disruption.

The consequences of this behavior are also many, including incorrect diagnoses, excessive and unnecessary reliance on testing, interference with the patient-doctor relationship, patient dissatisfaction, incomplete exchange of information, and less adherence to treatment.

I can’t say I wasn’t guilty of this interruptive behavior at one time or another in my medical practice, but for the most part I allotted plenty of time for each patient visit and allowed patients to relate their history pretty much as they wished. I set aside one hour or more for each new patient and a half hour for each return visit. I often learned details of patients’ lives that surprised me, interested me, and deepened my understanding of, and relationship with, patients and their families that stood us all in good stead at some point in our interactions.

I vividly recall a new patient who entered my consultation room, sat down, and immediately launched into a rapid-fire story about three mice in his chest. No introduction, no pleasantries, just abrupt and forceful recitation of a bizarre symptom. These three mice were chasing each other around and around in the left side of his chest, going faster and faster. Within seconds, I interrupted him because I knew at once that he was describing a form of tachycardia (rapid heart beat) and I didn’t need to hear more at that moment. But he put his hand up forcefully to silence me and restarted the same story. Once again I tried to jump in, but again he stopped me with a hand gesture. So, I decided to wait until the story ended, and in a few moments it did, with a crucial piece of information.

It seems that not only did the mice run faster and faster, but suddenly they would stop for a long pause, then start running again in the other direction. During that pause, when the mice were still, he felt lightheaded and once almost fainted. What this meant to me was that not only did he have a tachycardia we had to deal with, but he also had an interruption of his heartbeat during which no pumping of blood occurred. In simple terms, this meant that treatment to prevent the rapid heartbeats would likely cause longer pauses with no heart beat, and this could have really serious consequences. Indeed, we resolved the dilemma of so-called tachy-brady syndrome (the combination of periods of rapid and slow heart beats) with medication to slow the rapid part and a pacemaker to prevent excessive slowing or stopping of his heart. His story, as he told it when allowed to do so, led to the appropriate diagnosis and treatment.

There is a common plot theme in many crime dramas where a suspect, witness, or otherwise “person of interest” is questioned by the police and fails to disclose some information that they later reveal. When later asked why they didn’t mention that information earlier, the answer is usually that they didn’t think it was relevant. The detectives always respond by saying that they will decide what is relevant, not the subject being interrogated.

The point is that often nobody knows what might be relevant so it’s best to hear it all, if possible. Little details may have enormous significance in both a crime drama and a medical encounter.

Another example from my own experience relates to a patient I saw in the Emergency Department while covering weekend call for a colleague. The patient and his wife (who, a propos of nothing, turned out to be a high-school classmate of mine) had returned from a trip to Mexico a few days earlier. He developed gastrointestinal symptoms but thought they were related to what is commonly called Montezuma’s Revenge or just Traveler’s Diarrhea, and that they were unimportant and self-limiting. However, he became sicker and developed fever, headache, and muscle aches, and came to the Emergency Department on a Sunday morning.

I was certain his illness related to something he had eaten on the trip but he and his wife swore they had eaten the exact same thing at every meal during their travel. And she had no symptoms. I asked them again about their meals, but they once more insisted they had had the same foods everywhere. By the timing of his symptoms, I was pretty sure that whatever had happened had occurred during the last days of their trip, during which time they were in Guadalajara, Mexico. I went over every meal they had had and, suddenly, the patient’s wife had an “aha” moment. She recalled that on their last night in Mexico her husband, the patient, insisted on trying a pork dish and she had declined and ordered chicken. He had ingested pork infected with Trichinella, the parasitic worm that causes trichinosis. And he was damned sick.

We probably would have gotten the right diagnosis eventually, even if the “pork” tidbit had not come out right then. But that bit of information, at first hidden, was the key to early diagnosis and treatment. And early treatment in trichinosis is important to prevent disease progression, disease complications, and more lasting symptoms.

An even more unusual example of details that may seem extraneous leading to unexpected diagnosis and emergency treatment came from talking not with a patient directly but with a family member. The patient was a woman I had been seeing for high blood pressure and elevated levels of blood cholesterol; her problems were easy to manage. Her husband, a warm and friendly gentleman always accompanied her and, while the patient prepared for examination in another room, I always chatted briefly with him. On one occasion, I casually asked how the drive to my office had been; they came from a distance away and he always drove. He laughed slightly and said it was a little different because his wife had driven, since he had felt a “funny numbness” in his left hand. 

My first thought was: Could this healthy appearing man in his mid-sixties be describing neurologic symptoms requiring emergent intervention? I asked his permission to do a simple examination, explaining that I just wanted to be sure that what he was describing wasn’t something serious. He seemed dubious, but his wife, he, and I, had a warm and trusting relationship, so he allowed me to proceed. On a brief examination, I heard a bruit in one of his carotid arteries, an abnormal sound made by turbulent blood flow, usually due to a blockage in the blood vessel. This finding, combined with the symptoms of numbness, strongly suggested an impending stroke. Within a relatively short time, he was examined by a vascular surgeon colleague of mine, admitted to the hospital, and operated on to relieve a severe obstruction to blood flow in a major artery supplying blood to the brain. All from a casual conversation about nothing important.

They say talk is cheap. It may be (but not with a therapist), but it doesn’t mean it’s unimportant. Details may emerge from patients and others that are vital to both diagnosing and treating illnesses and to understanding the circumstances in which medical issues arise. If you are a patient, prepare to be interrupted but try to say all of what you want to report. Don’t hold back information because you think it’s not relevant or because you don’t want to “waste” the doctor’s time.

And to my colleagues, I know time is precious, time is money, you’re under pressure to be more efficient, you have to see more patients. I know all of that. But if you cut off the flow of information, you may miss important details and you will do your patients a disservice, sometimes with serious consequences.