Saturday, July 10, 2010

Talking to Patients

Years ago I read an article about what patients could or should expect from a visit to their doctor. There were four patients that recounted their experiences during recent doctor’s appointments. The length of time they had to wait, the details of their visit including actual time spent with the doctor were included. One of the patients complained that the doctor spent most of his time talking to her. I would bet that this particular doctor was the most thorough and conscientious of all the doctors that were presented in that article.

When a patient walks into a doctor’s office for the first time, the doctor faces a myriad of possibilities. In my practice, which is general surgery, I usually assume a new patient has or is suspected of having a surgical problem. Of course this differs from the primary care physician setting where the problem could be anything from headache to hemorrhoids. It is the primary care doctor’s task to sort out all the endless possibilities and determine the best medical approach for each. This is their great challenge, one that may be faced twenty times a day or more.

Fortunately, for me, the surgeon has a task that is a bit easier, at least initially. When I am asked to see a new patient, most of the time there is some information that comes with the request, usually something short and simple, ie: Gallbladder disease, abdominal pain, cold leg, etc. This very brief summary gives me a bit of direction, although occasionally it can lead in the wrong direction.

So, the first, and often the most useful, thing that I do is to sit and talk to the patient. Probably 98% of the time the patient will tell me what’s wrong and all that I need to do is confirm this presumptive diagnosis with the physical exam and appropriate testing. This is true for almost any condition, be it acute appendicitis or hemorrhoids.

But, how does simple talking do all this? The things that go through a doctor’s head, at least mine, when I take a history from a patient are myriad. First and foremost is, “Is this patient ‘sick’.” By this I mean does the patient seem to have a severe, possibly life threatening condition that warrants immediate hospitalization and possibly emergency surgery? Patients that cannot sit up, are afraid to move or are unable to give any history because they are too ill usually need to be in the hospital. It is one of my unwritten rules that patients that look sick usually are. Experience teaches doctors, particularly general surgeons, to be vigilant, assume the worst and do all that we can to achieve the best outcome.

But, I’ve strayed away from the point of this article. Talking to patients is the single most important part of patient visits. When I went to medical school the greatest amount of time was spent on learning the natural history of the many various diseases, all the possible presenting symptoms and signs and how to obtain this information from a sick patient. Unlike House I don’t believe that patients always lie. Most want to get better and most of the time the questions that I ask cannot be answered in misleading way. Starting with the simple question, “What brought you in here today?” and then paying attention to the patient’s answer will, in a few minutes, provide almost all the information necessary to begin that individual on the road to recovery.

Approaching a patient with abdominal pain provides an excellent example. In the days before routine CAT Scans the evaluation of patients presenting with abdominal pain required the skills of a detective; the history and physical exam, along with limited diagnostic testing, were the mainstays of diagnosis. The abdomen, in the days before CAT Scans and MRI’s, was a black box filled with vital organs and often inaccessible except through surgery.

The abdomen is usually divided into three segments, epigastrium, which is above the umbilicus (belly-button), mid-abdomen, the level of the umbilicus, or hypogastrium, which is below the umbilicus. The first thing I will usually ask is where did your pain start. Sometimes I get an answer like “In the bathroom”; some people are so literal. But, once properly directed, the starting point of the pain will go a long ways to narrowing the choices for the offending organ.

Epigastriium usually means stomach, duodenum, gallbladder, liver or pancreas. Mid-abdomen refers to the small bowel or the right side of the colon and hypogastrium usually refers to the left colon. These divisions are in no way arbitrary, rather they correspond to the nerves that supply the various organs and where the nerves will refer pain. For instance, the gallbladder sits in the right upper abdomen, but very often gallbladder pain is felt in the middle. This is because the visceral nerves refer the pain to the middle. Only after a gallbladder becomes more inflamed do the parietal nerves come into play and the pain then becomes localized over the offending organ.

Duration, quality and associated symptoms all direct me to a working diagnosis that only needs to be confirmed. Physical exam, blood/urine tests, imaging studies primarily are used to confirm the working diagnosis and to eliminate other possibilities. I’ve learned that relying solely on imaging studies is often misleading.

For instance, just recently I was called from the Emergency Room at one of the hospitals and informed of a patient that the admitting physician wanted me to consult. The ER physician said she had right sided abdominal pain and that an ultrasound had revealed gallstones. The white blood cell count was elevated, but she was otherwise stable. This patient, as presented to me, was properly admitted to the hospital, but a patient with these clinical findings generally is not a life and death emergency and can usually be seen later in the day. It is very rare for uncomplicated cholecystitis (gallbladder inflammation) to require immediate surgery.

I saw the patient a few hours later and the history that I received led me to very different diagnosis. Her pain was in the right lower abdomen, unusual for gallbladder disease, and she said it was very severe. She also had a history of severe cardiac disease. There was associated nausea and constipation. Physical examination revealed severe tenderness in the right lower abdomen and no tenderness in the right upper abdomen, where the gallbladder usually resides. I began to be concerned that she could have had appendicitis, which would require emergency surgery. The other possibility I considered was ischemic colitis (inflammation of the colon caused by poor blood supply), also a serious condition that could be a life threatening emergency.

When I checked the tests that had been done I saw that a CAT scan had also been done, which seems to be almost routine these days. The findings were thickening of the cecum, which is the first part of the colon, and a normal appearance of the appendix. With all this information I determined that the patient likely had ischemic colitis, but that surgery was not necessary at that time. The following day she had a colonoscopy which definitively confirmed the diagnosis and she is now recovering; responding to the non-operative therapeutic regimen that was started. She still has her gallbladder and her asymptomatic gallstones.

What is apparent is that properly talking with the patient, obtaining a clear history, points the physician in the right direction. Talking to patients is a skill that is easy to develop and actually saves time and money. It often takes no more than five minutes to gather the most pertinent history from a sick patient and, as I’ve shown, the rest of the workup flows out from this relatively short, but very informative interview.

So the next time you go to your doctor and he or she spends most of your appointment talking to you, be thankful; thankful that you have a doctor that cares enough to take the time find the right answer in the right way.