Obscurity in Medicine

photo by Josh Scholten

Be obscure clearly.
~E. B. White

As a family doctor, I work at clarifying obscurity about the human condition daily, dependent on my patients to communicate the information I need to make a sound diagnosis and treatment recommendation.  To begin with, there is much that is still unknown and difficult to understand about psychology, physiology and anatomy.  Then throw in a disease process or two or three to complicate what appears to be “normal”, and further consider the side effects and complications of various treatments — even evidence-based decision making isn’t equipped to reflect perfectly the best and only solution to a problem.  Sometimes the solution is very muddy, not at all pristine and clear.
Let’s face the lack of facts.  A physician’s clinical work is obscure even on the best of days when everything goes well.  We hope our patients can communicate their concerns as clearly as possible, reflecting accurately what is happening with their health.  In a typical clinic day we see things we’ve never seen before, must expect the unexpected, learn things we never thought we’d need to know, attempt to make the better choice between competing treatment alternatives, unlearn things we thought were gospel truth but have just been disproved by the latest double blind controlled study which may later be reversed by a newer study.   Our footing is quicksand much of the time even though our patients trust we are giving them rock-solid advice based on a foundation of truth learned over years of education and training.   Add in medical decision-making that is driven by cultural, political or financial outcomes rather than what works best for the individual, and our clinical clarity becomes even further obscured.

Over thirty years of doctoring in the midst of the mystery of medicine — learning, unlearning, listening, discerning, explaining, guessing, hoping,  along with a little silent praying — has taught me the humility that any good clinician must have when making decisions with and about patients.  What works well for one patient may not be at all appropriate for another despite what the evidence says or what an insurance company or the government is willing to pay for.  Each person we work with deserves the clarity of a fresh look and perspective, to be “known” and understood for their unique circumstances rather than treated by cook-book algorithm.  The complex reality of health care reform may dictate something quite different.

The future of medicine is dependent on finding clarifying solutions to help unmuddy the health care decisions our patients face. We have entered a time of information technology that is unparalleled in bringing improved communication between clinicians and patients because of more easily shared electronic records.  The pitfall of not knowing what work up was previously done will be a thing of the past.  The risk and cost of redundant procedures can be avoided.  The patient shares responsibility for maintenance of their medical records and assists the diagnostic process by providing online symptom and outcomes documentation.   The benefit of this shared record is not that all the muddiness in medicine is eliminated, but that an enhanced transparent partnership between clinician and patient develops,  reflecting a relationship able to transcend the unknowns.

So we can be obscure clearly.   Lives depend on it.

What’s Beneath the “Chief Complaint”

Any primary care clinic has a schedule that lists the appointments of the day in incremental time slots.   There is a column for the name of the patient, the patient’s age, and always there is a place for the reason for the visit–the “chief complaint” according to medical parlance.

A quick review of the “chief complaints” for the day gives the physician a sense of how clinic will flow.   There are the seemingly “quick” concerns, like a blood pressure check, sore throat or ankle sprain, and then there are those that will predictably take longer such as fatigue, trouble sleeping, back pain, or headache.

All health care providers are aware that the chief complaint may not be what the patient really wants to talk about.   Finding out the real concern can be part of the detective work the physician must do.  Sometimes it doesn’t actually reveal itself until the physician’s hand is on the door knob, ready to say goodbye and move on to the next patient.

So I can’t depend on a seemingly routine and straight forward chief complaint to be what it appears on the daily schedule.   When I knock on the exam room door, I need to expect the unexpected.  Otherwise,  I’ll have failed my patient and not done what I’m trained to do–look for what is “beneath” the chief complaint.

Examples:

“itching” – a patient who reports 2-3 months of daily itching, worse at night, with no other symptoms and no apparent rash.  Treatment for scabies showed no benefit, there has been no significant relief from antihistamines or topical corticosteroids.   Examination is unremarkable with no skin findings other than the excoriations from scratching.  Lab work reveals mildly elevated liver function tests.  Additional labs reveal no acute or chronic infectious hepatitis but further work up confirms primary sclerosing cholangitis.

“back pain” in a patient who had been seen with similar low back pain six months previously, but it has been intermittent up until a week prior to this visit when the patient’s legs feel heavy when going up stairs.  Exam reveals an abnormally “stiff” gait but no leg swelling or neurologic abnormality.  Sed rate is elevated and subsequent MRI scan shows bilateral iliac thrombosis due to a congenitally absent inferior vena cava.

“memory lapses” in a patient who notes two weeks of feeling that it was a struggle to remember something that had happened only a few moments before.  Significant recent stress with fatigue but mental status exam and physical exam appears entirely normal.  Screening lab work reveals a significantly elevated calcium, with subsequent testing showing hyperparathyroidism.  Surgery to remove the offending parathyroid gland reveals incidental papillary thyroid cancer as well.

“constipation” in a patient who has noticed bloating in her lower abdomen for several weeks.  She has had normal cycles on birth control pills, has a negative pregnancy test, and a rock hard 18 week size mass in the pelvis.  Subsequent surgery reveals a rare non-metastasized ovarian malignancy requiring aggressive chemotherapy.

“fatigue” in a patient who is puzzled about having slept for almost 20 hours straight.   General disheveled malnourished appearance and smell suggests issues with being able to do basic self care and an examination reveals needle tracks on both arms.  Admits to daily heroin use but doesn’t think it is connected to the excessive sleep need since drug use has not changed over several years.

“fever” with headache, myalgias, and nausea for two days in a patient whose rapid strep and influenza screen is negative, lab showing normal white count with a left shift.  Blood cultures eventually grow strep viridans from subacute bacterial endocarditis on a previously undiagnosed bicuspid aortic valve, presumably from a dental cleaning a few weeks before.

“rib pain” in the left lower anterolateral chest wall of a patient with a week of dry cough, congestion, and low grade fevers.  Vital signs and pulse oximeter readings are normal, as well as a plain chest xray, a urinalysis shows some red blood cells. Scan of the abdomen rules out kidney stone but suggests a subtle infiltrate in the left lower lobe.  D-dimer is mildly elevated and scan of the chest shows multiple infarcts most likely related to use of combination oral contraceptives.

Any of these routine “chief complaints” could have led me to conclude an every day diagnosis, forming a treatment plan based on standardized clinical guidelines with prediction of an uncomplicated recovery.   But complacency in a primary care setting would be disastrous.

My job is to peel down through the layers and find what lies beneath the symptom that was the patient’s reason for seeking help.   It is that every day mystery that keeps me coming back, day after day, wanting to know what will happen next when I open the exam room door.