The patient was impoverished and had been in and out of jail for years. His health was poor, and among our many worrying clinical findings was the possibility of undiagnosed advanced colon cancer.
A fellow med student and I spent almost an hour taking the patient's history. We noticed that many of the patient's problems had started two years ago. A fall two years ago had caused his left eye to permanently deviate outwards ("acquired exophoria"). No one had ever treated it, and he had been seeing double ("diplopia") ever since. Later on, he told us the story of how, two years ago, he went for a drive even though he wasn't supposed to. Just across the street from where he started his car, he crashed at full speed into a parked vehicle. The crash badly fractured his hip, altered his gait, and sent him to prison. He hadn't driven since.
The patient had communicated something important here that I had entirely missed.
My med school class just had a lecture about the eye, and I mentioned to a professor that I had recently examined a patient with diplopia and acquired exophoria. The professor replied that diplopia is very serious and, if uncorrected as in this patient, can thoroughly mess up someone's life. He said we should have made it our priority to identify the underlying cause and come up with a treatment plan. "You can't do much while seeing double," he said.
It was only then that I put two and two together: you can't drive a car while seeing double, either. The diplopia almost certainly caused the car crash, which caused the hip fractures, which wrecked his gait and caused him constant pain. Dominoes.
I've only just begun getting an intuition for which medical problems are most pressing. As it improves, I'll be able to do better for my patients.
