What Your Doctor Really Thinks

Diagnosing the Doctor-Patient Relationship

Ian Blumer

• Publisher: Dundurn Press
• Year: 1999
• ISBN:
  9781459726123
• Topic: Medicine
• Subtopic: Caregiving

Q. You've been sent for a stress test. Does this mean your doctor thinks there's something wrong with your heart?

A. Not necessarily. Doctors often schedule stress tests when they are certain a patient's heart is healthy. So why the test?

In What Your Doctor Really Thinks, Ian Blumer looks at the doctor-patient relationship, and explains what your doctor will and won't tell you in the examining room. Blumer lets you know what is going on in your physician's head, and suggests what should be going on in your head, when you present him or her with symptoms. Fatigue, chest pain, headaches, abdominal pain, dizziness, shortness of breath... Blumer covers a variety of symptoms and discusses what direction the examination may take.

This book is a look into the psyche of the doctor and the patient during their meetings. It is a discussion of what both parties might be thinking, but not saying, and it reveals the so-called "mind games" that often take place. It tells people why, without their having even realized it, they have just left a doctor's office not knowing if the "growth" they have is worrisome or harmless, if they have a dim future or a good one. It tells people why doctors are often evasive, or, at times, downright rude.

What Your Doctor Really Thinks is not an aid to self-diagnosis. It is not a compilation of medical anecdotes glorifying the practice of medicine. And it is not a self-help guide to teach you about the disease that afflicts you. It is, rather, an aid to understanding your doctor, and to understanding yourself. Everyone from the health-conscious to the hypochondriac will find familiar symptoms in Blumer's book. You may find comfort in knowing that your symptoms are nothing to worry about; or you may find reason to see your doctor about something that may be more serious than you had thought. Regardless, you will learn not just what a doctor's diagnosis might be; you will also learn why they have made that diagnosis, and what the diagnosis means.

Chapter One

FATIGUE, NEUTRALITY, AND GREED

A woman of 38, Mrs. Mary Woods, was referred to me by her family doctor because of persisting fatigue. I ushered her in from the waiting room, introduced myself, and brought her down the short corridor into the examining room.

“Have a seat,” I said, gesturing to the chair opposite mine. “So, what brings you to see me today?” I asked.

“Doctor, I’m just plain exhausted. I’m tired all the time.” Mrs. Woods did indeed look fatigued. “My get up and go just got up and went. From the moment I get up until the moment I get into bed all I want to do is rest. I get maybe a little bit of energy mid-day but I’m a wreck the rest of the time. I wonder if I have Chronic Fatigue Syndrome.” She looked at me expectantly.

And I looked back neutrally. At least I sure tried to look neutral. Because I didn’t want her to know my secret: I don’t like seeing patients whose main complaint is fatigue. Why? Because almost invariably it is due to depression. And when I tell patients that, they usually immediately conclude that I believe they therefore have “nothing wrong” with them (which is transparently not true; depression is very real) and moreover that I have obviously missed the boat and failed to figure out what their true illness is. And then, truth be told, some of these patients conclude I am either incompetent (which my wife tells me really just isn’t true) or am “just like the rest of them” — them being the vast numbers of doctors who obviously don’t really care about the patients they look after, they just want them in and out of the office on a treadmill to help finance their golf club dues (and heck, I don’t even play golf; though I do admit to having gone sailing on occasion).

What do you think might be causing Mrs. Wood’s tiredness?

1. Chronic Fatigue Syndrome

2. cancer

3. an underactive thyroid gland (“hypothyroidism”)

4. don’t know yet

Answer: 4. It is impossible to know at this point what is causing her problem. We can make an educated guess, but I can tell you right now that malpractice lawyers love it when doctors make educated guesses. I bet you can figure out why.

So, where do we take things from here? Well, we do what doctors have been doing for hundreds (probably thousands) of years. We get more history — “history” being what the patient tells us (as opposed to “physical,” which is the physical examination of the patient).

“Mrs. Wood’s, please go on,” I said.

“I don’t know what else to say,” she replied.

This is the tricky part of an interview. To inquire, but not to lead.

“Tell me more about your fatigue,” I said. Now all I’ve basically done is just ask the same thing of her twice. Redundant? Perhaps. But it works. Asking things twice may give the impression of not paying attention to the original answer, but experience proves that patients will almost always elaborate if asked the same thing twice.

“Well, I guess I’ve felt this way for a year or so. Maybe two years. No . . . when I think about it I guess I haven’t felt right for longer than that, it must be going on two and a half years or more.” Mrs. Woods was worried. Like many people, she believed that a symptom going on for that length of time must be due to some dread disease.

So, was she right? Is there an increased likelihood of a serious disease if fatigue is chronic?

1. yes

2. no

3. maybe

Answer: 2. In fact the longer that someone has had fatigue the less likely it is that there is anything sinister underlying it. As an example, someone is not going to have the luxury of being chronically fatigued if they have metastatic lung cancer.

As Mrs. Woods had paused, I asked her what “fatigue” meant to her. Now you might think this would be self evident. Fatigue is fatigue. Ah, if only the practice of medicine were that straightforward. In reality one person’s fatigue is not another’s.

“It’s exhaustion doctor. Just plain exhaustion.”

Whereas tiredness for Mrs. Woods was a sense of exhaustion, for others it might be a lack of interest in things or a feeling of somnolence. The differences can be legion.

Were someone complaining of persisting or recurring somnolence to the point that they were falling asleep at inappropriate times, such as when driving or in the middle of conversation, then it would be imperative to evaluate them for the possibility of:

1. sleep apnea

2. neuroses

3. a chronic viral illness

4. African Sleeping Sickness

Answer: 1. In this condition, affected individuals usually believe they have had a good night’s sleep, but in fact are sleeping fitfully, having episodes of terrible snoring (sometimes as loud as a jet plane taking off!) and other periods where they stop breathing altogether. The patient of course would not know this. It is noted indirectly — usually when a patient tells me that their spouse is worried about them. The typical comment is along the lines of “Doc, my wife keeps hitting me in the middle of the night because I stop breathing and she thinks I’m not going to start again.” More difficult to sort out is the sleep apnea patient who, as is often the case, cannot tell me if his wife finds that he sometimes stops breathing because she has long ago kicked him out of the bedroom. The snoring was too much for her. One day it would not surprise me if I get simultaneous requests to see both husband and wife for fatigue.

People are often judged by the company they keep. Symptoms are assessed in much the same way. Hence, my next question to Mrs. Woods.

“Mrs. Woods, have you noticed anything else?”

“Yes, I find I can’t concentrate on things. And my work is suffering. I’m getting worried that my boss is going to notice. Sometimes it’s not too bad and I can put in a couple of good hours but most of the time it’s a struggle.”

“Anything else?”

“Well, to help you I brought this list with me — it tells you everything.”

Do you think such a list is:

1. often helpful

2. always helpful

3. never helpful

Answer: 1. But not for the reasons you might expect. Studies have shown that the greater the number of symptoms a patient has identified on a list the lesser the likelihood of any of them being due to a serious disease. So when I see a long list emerge from a wallet or purse, surprising as it seems, this is often a reassuring finding. The downside of a list is that the symptoms so carefully itemized end up being discussed like a check-list rather than real symptoms experienced by a real person. The important symptoms would invariably have been obtained during the course of the interview anyhow and in such a way that conversation would have allowed more fluid elaboration of the details. Although many a patient fears that they will miss a key finding if it is not written down, in fact that’s seldom the case. The overlooked symptom is rarely important.

She tells me of her headaches and her dizziness. Her belly pain and her constipation. Her shortness of breath and her chest pain. Her aching and her stiffness. I interject occasionally but for the most part I simply let her speak. It is a difficult balance. Each and every one of her symptoms could be significant, yet to explore them all in detail would take hours and more importantly could lead to losing the forest for the trees.

As the interview progressed it gradually came out that Mrs. Woods had separated from her husband after an increasingly hostile relationship. She had two children, one of whom was having major problems at school.

With all this information now available, what is the most likely diagnosis?

1. hypothyroidism

2. cancer

3. depression

4. heart disease

Answer: 3.

She was depressed; pure and simple. As my report to the family doctor said; “the chronicity, multiplicity, and nonspecificity of this patient’s symptoms are typical of functional complaints.” Now what the hell does that mean? Well, basically it means that we have someone with a whole potpourri of chronic, vague complaints which have been present virtually forever yet in whom no “physical” disease has ever developed. Note that a very likely diagnosis was established without my having had to ask her more than a handful of questions and indeed without her even yet having had a physical examination. And not a single blood test or x-ray was done. The moral of the story: the history is the key to diagnosis. The history. What the patient tells you. That is where the answers usually lie. Or at the very least, where the clues emerge.

But taking a detailed history is very time consuming. And doctors don’t have a lot of time. Or at the very least they don’t make a lot of time. Family doctors in fact will often book patients six to ten minutes apart. That is a necessity because of both the number of patients that want to (or, ahem, need to) be seen and because the amount you get paid per patient is not a lot. Most doctors are, to put it bluntly, piece workers. It just happens to be that the pieces are people. So if you want to have a good income (and rest assured, most doctors do, and I make no value judgment here: I too certainly like to make a very nice living) there is a strong impetus to not spend a long time with each patient. Consultants have the luxury of being paid more per patient and so have the opportunity to spend more time with them.

Now if a family doc has allotted six minutes for a patient visit, that is fine when all you have is a sore throat, but if you want to discuss your fatigue, do not be surprised if your doctor’s practised look of neutrality is not so convincing. Far better to let the doctor’s office know in advance that you have a new problem, what it is and let them try to find a longer appointment for you.

Mr. James Ferguson, like Mrs. Woods, came to see me because he was tired. And like Mrs. Woods he complained of feeling exhausted and worn out. But unlike Mrs. Woods, he’d feel not too badly when he would awaken but by mid-day he had to leave work and rest.

So, does that sparse information give us a significant clue as to the cause of this patient’s fatigue?

1. yes

2. no

3. maybe

Answer: 1. The warning lights went on. Mine that is. Okay in the morning, but worse as the day progresses. That is often a clue of some serious pathology lurking. The body is refreshed after a night’s sleep but fades quickly thereafter.

“Have you noticed anything else?” I asked him.

“These sweats are driving me crazy,” he answered. “Every night around three in the morning I’ll wake up drenched. My pyjamas get soaked. It’s gotten to the point that I have to roll over to the other side of the bed because its drier there.”

What should be the very next question I ask Mr. Ferguson?

1. is he coughing

2. is he having diarrhea

3. does he have a water bed

Answer: 3.

“Do you have a water bed?” I asked. You bet I asked. I had one patient I worked up extensively for the problem of night sweats only to find out he had recently obtained a water bed and liked the thermostat turned up. Way up. I don’t like feeling foolish.

“No, no water bed. Same bed as always,” he told me.

Sweats. Night sweats. That can be a big problem. Both for the annoyance it represents for the patient and for the sometimes sinister disease that can underlie it. Could Mr. Ferguson have Hodgkin’s Disease (a type of lymph gland cancer), I wondered? Or tuberculosis? Or an infection of a heart valve (known as endocarditis)?

I asked him about other symptoms, but few were found. As I continued to talk to Mr. Ferguson, I reminded myself that when I examined him I would have to check carefully for the presence of any swollen lymph glands. I asked Mr. Ferguson to change into an examining gown and I left the room. I went into my private office, pulled a textbook off the shelf and opened it to the section on the different causes of night sweats. And by having done so, I was participating in an age-old secret ritual.

The ritual to which I refer is:

a) a covert way to make up for a deficient knowledge base

b) a nice break from being at the patient’s bedside...

Table of contents

• Cover
• Title
• Copyright
• Table of Contents
• Introduction
• 1. Fatigue, Neutrality, and Greed
• 2. Chest Pain, Needless Tests, and What They Don’t Teach You at Harvard Medical School
• 3. Headaches, Caring for Colleagues, and Sleeping with Patients
• 4. Weight Loss, Rarity, and Being a Star
• 5. Abdominal Pain, Chronic Pain, and Why Dracula Needed a Dermatologist
• 6. Back Pain, Death, and Knights in White Dresses
• 7. Fever, Glamour, and Fearing the Lights
• 8. Joint Pain, Love, and Drug Company Reps
• 9. Weight Gain, Anhedonia, and Seeking the Truth
• 10. Diarrhea, Constipation, Silver Patients, and Scary Interns
• 11. Weak and Dizzy; Oh Doctor I’m So Weak and Dizzy
• 12. Shortness of Breath, Choosing Your Poison, and Using a CAGE
• 13. Sore Throats, Second Opinions, and Fragile Egos
• 14. High Blood Pressure, High Overhead, and Highly Important Assorted Miscellanea
• 15. Conclusion