The Doctor-Patient Interaction

     The practice of medicine is both an art and a science, and a proper understanding  of the mind-body interaction (pace Rebecca Goldstein's novel "The Mind-Body Problem") is important. In this blog I will restrict myself to a discussion of interactions in the office, because diagnosis in the emergency room calls on a different mind-set. My general practice is to greet the patient in the waiting room, escort the patient to my office for the interview, and  then escort the patient to the exam room where the patient changes into an examination gown with the possible assistance of my office nurse. I then examine the patient, making conversation as I do so, sometimes disease directed and sometimes not, and then see the patient again in my office to discuss my findings, my conclusions, and my suggestions for treatment and/or further tests, but always with at least a partial explanation of what I think are the cause(s) of my patient's symptoms.

     Gestalt and understanding  plays an important part in diagnosis. I always have a mental image of the visage and ambulation of my patient at our last meeting, and I automatically superimpose that image on their present gait, posture and facial expression. It is not then difficult to determine that the patient feels happier, or more tense, or healthier, or more tired even before a word is spoken and a single complaint is voiced. The patient rarely denies my observation of his/her change in appearance, but we may differ in our assessment of the cause, and our degree of difference in our two interpretations often depends on the patient's presence or lack of both insight and denial. Needless to say, my interpretation is greatly facilitated by my previously having obtained the patient's mental map of disease at our first meeting: what it means to the patient to be sick, how he/she feels about doctors in general and taking medicine in particular, previous experiences with doctors  for the patient , especially as a child,  and what resolution the patient is looking for. A secondary question of some import is whether the answer and treatment agreed upon has to satisfy only the patient, or if the spouse's wishes and beliefs must also be taken into consideration.

     Unlike Newton's Third Law, where each action has an equal and opposite reaction, in humans the smallest action (i.e. input to the system, usually verbal) can create a reaction quite out of proportion to the inciting incident. This is most easily seen in patients with poor control of explosive anger. Unfortunately we have no pills to treat anger. We also have many symptoms that may be  caused by the turning of anger inward or by anxiety:  irritable bowel syndrome, headaches, sweating, palpitations, shortness of breath, chest pain, dizziness, insomnia, fatigue, muscle aches, peripheral numbness, etc. An important duty of the internist or family doctor is to decide, with the help of history taking, physical examination and tests whether the constellation of symptoms is due to a disease process, to stress/anger/anxiety, or to a combination of the two in that certain symptoms may heighten a patient's anxiety.

     Just as in physics experimental facts are interpreted in the light of a theory, so in a patient symptoms must be interpreted in light of the physician's knowledge of disease, disease processes, and anatomy. It is  true that if the patient is listened to carefully enough (i.e. in the proper diagnostic framework) he/she will tell the doctor the cause of the symptoms at least 80% of the time. Unfortunately, the correct interpretation of the patient's history is sometimes obvious only in retrospect, e.g. at a CPC conference. Part of the problem is that  if a physician does not think of a disease, he/she will not diagnose it. (And let us not forget the diagnostic computer algorithm that could never diagnose pregnancy because pregnancy was not listed as a disease.)

     There are always three questions that a competent physician must ask on each interaction with a patient: (a) is the patient ill, (b) does the patient need hospitalization, and (c) what condition could the patient have that may shortly cause an avoidable death if it is not diagnosed? (The same questions should be asked regarding a patient seen in the emergency room, but since the patient may be lost to follow, the diagnostic/investigative pattern is different than for the office.) This is where having a family doctor who knows the patient is important. We  know which patients maximize or minimize their symptoms, what diseases run in the family, how well the patient follows advice and which patients will only volunteer additional symptoms when asked directly. The answers and the results of the physical exam are our data, and our conclusions and "write-up" are the  suggestions and prescriptions that follow. The patient also must be satisfied with  (i.e. accept) your diagnosis and plan of treatment or else compliance will not follow.

     The physician's diagnostic acumen and interactive skills really come into play when the physical exam is totally negative. If the patient has a complaint, the statement "I find nothing wrong with you" usually falls on unhearing or disbelieving ears. This is not the same as saying "it's not serious", which is what most patients would like to hear. The physician should list the significant and worrisome diseases the patient does not have, e.g. heart failure, appendicitis, throat cancer. At this point the patient should also be asked what diagnoses the patient has entertained or is most worried about, and be reassured as much as is possible. And whether or not a precise diagnosis is arrived at, the plan for following-up must be carefully explained and written out. I also often call the patient the next day to see if there are any further questions that occurred to the patient.