19 January 2012

Glad I asked

When I am assigned a patient, I am handed a medical chart with write-ups of their past visits. The chart contains invaluable information. I can quickly ascertain whether the patient's weight has dropped, which could be a sign of serious illness. If a patient's blood pressure is high, I can instantly determine whether it developed recently.

Sometimes the chart contains scattered clues that, only when taken together, suggest a serious and unaddressed illness. I like reading through a chart the same way I read a mystery novel: scouring it for hidden leads and seeking to unmask an unseen culprit.

One patient presented in our free clinic for a minor complaint. An old entry in her chart matter-of-factly noted that she was still on a medication that she began after having a significant organ removed as a young adult (I have to be vague because of patient privacy). The chart did not offer an answer for the question that raced through my mind: why had the patient needed this major surgery?

So when I met with the patient, I asked. She said it was because of cancer, but she refused to elaborate and said she doesn't talk about it. We moved on, but I sensed that this revelation was potentially major and that I ought to find out more. Over the course of the visit, I determined that she was at high risk for developing cancer.

I revisited the point later, using a less direct line of questioning. Eventually she opened up to me that she had recently noticed a large pelvic mass that is constantly growing, but that she was not emotionally ready to have anyone examine it. Her description of the mass alarmed me and instantly made me think of a tumor. Despite my best efforts, she simply would not submit to examination or imaging, and I had to let it go. My efforts were hopefully not in vain. The mass is now mentioned in her chart, and when she returns to clinic a different med student will encourage her to have it examined. And at that next visit, she may feel more ready.

We learn in class that a careful history can reveal many medical diagnoses. There is a real art to the interview. One has to ask probing and uncomfortable questions while still maintaining the patient's trust. One has to cast a wide net so as not to miss a major medical problem, but also intensely follow up on particular leads. And patients can sometimes have poor memories, or be reluctant to bring something up.

I think the delicacy and intricacy of taking a medical history is one reason why computers will not be replacing primary-care physicians anytime soon. The interview is a distinctly human and social part of medical practice, which is one reason why I really enjoy performing it and reflecting upon it.