02 January 2013

Diagnosis III

A longtime patient had come in complaining of progressive fatigue, weakness, and numbness in her hands and feet. Her primary-care physician and I were taking a few seconds to skim her medical chart before we stopped by her room to examine her.

I glanced at the patient's weight and noticed that she was borderline obese. A potential diagnosis came together in my mind. "Has this patient ever had gastric bypass surgery?" I asked.

Him: "No."

Me: "Darn."

Him: "Why do you ask?"

Me: "I was wondering if maybe she has a vitamin deficiency, like B12, that's causing her symptoms." Some types of gastric bypass, such as Roux-en-Y procedures, remove some of the small intestine, thus reducing absorption of certain critical vitamins. Patients are supposed to take hefty vitamin supplements for life as a result.

Him: "It was a nice thought."

We went in to see the patient. She was very unhappy because she felt like she had no energy. Her family and job were stressful. And she was disappointed with her weight. "Even after getting that gastric bypass, I still weigh too much."

The doctor's eyes lit up. "How long ago was your gastric bypass?" he asked.

"It happened maybe 4 years back," the patient responded.

"I assume after your procedure they prescribed a special mega-vitamin."

"Yeah, but I didn't like it. I stopped taking it maybe half a year ago."

I couldn't stop myself from grinning.

Although I'm not skilled enough to be seeing patients entirely on my own, sometimes I've been able to make diagnoses that the doctors I'm with have overlooked. Part of the reason is that my training is uneven. In medical school, we spend a lot of time learning diseases that are rarely encountered in clinical practice. We also have seen so few patients that we have little sense of what is common and what is uncommon, which diseases make sense and which ones don't. When I see a patient, the list of diseases I'm considering differs from that of a seasoned physician.

But sometimes the patient doesn't have the disease a seasoned physician expects, and these are the times I get to shine. Sometimes, two minds are better than one. I wouldn't have expected it, but I think that patients get better care when they are examined by both a physician and a medical student as opposed to only a physician.