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.

New Medical Device = Guinea Pig Patient

     By now almost all of my readers have probably read about the horrific results that have developed and will  continue to develop in some patients whose artificial hip is the new one of metal-on-metal rather than the old one of metal-on-plastic.The old artificial hip used a metal rod with an attached metal ball to replace the upper half of the femur, and installed a plastic cup into the acetabulum, or that part of the pelvis with  which the femoral head fitted and subsequently pivoted, rotated and articulated , just as in the old hip joint. The new artificial hip used a metal cup instead of plastic so there was constant grinding of metal-on-metal.

     Unbeknownst to anyone, this constant grinding of metal on metal created thousands if not millions of tiny metal splinters and released them around the joint space. The white blood cells engulfed and tried to destroy them as if they were foreign invaders (which is why an unattended splinter in your finger turns red and the surrounding area gets tender). The subsequent release of inflammatory chemicals generated by the white blood cells apparently caused chronic pain and also damaged some of the leg muscles around the joint, necessitating the replacement of the new metal-on-metal joint with the older metal-on-plastic one.

     I mention this not to criticize the inventor of the new artificial joint, but to illustrate the dangers inherent in replacing a " tried-and-true" device with a new one that has theoretical advantages. There is no experimental way to mimic the effect of inserting a medical device into a human being for five minutes, let alone five years. In my opinion unless a medical device immediately provides a tangible benefit that no previous device did, you should let someone else be the guinea pig and have it inserted in them for the first six months to five years of the release of the new device. BTW, did you know that the salesman for the new orthopedic device often accompanies the surgeon into the OR to verbally instruct in  the insertion of the device? You certainly have the right to (a) ask the surgeon how many of these devices he/she has personally installed, and (b) ask that only doctors, nurses, etc. be allowed into the OR while they are operating on you, or that you be told who besides the surgeon will be present.

     The FDA clearance of a device does not imply verification of its "duty cycle" This is an engineering term. A light switch has a (tested) duty cycle of, say 10,000, meaning that it can be turned on and off at least 10,000 times before it fails to work., A light bulb has a defined duty cycle based on how often it is turned on and off, and for how long it is kept lit each time. A soldier's rifle has a tested duty cycle, as does your car's ignition and  your electric garage door opener. (For a wonderful movie  about the vibration duty cycle of the tail of an airplane, I heartily recommend "No Island in the Sky", based on the novel of the same name by Nevil Shute, and starring James Stewart as the airplane designer and co-starring Marlene Dietrich and Glynis Johns.) But the duty cycle of any device inserted into a human being is NEVER tested under true operating conditions. Thus we have had some  heart valves that shattered, or some that  clotted in an unacceptable way. We have had new materials inserted into human bodies that were subsequently rejected by the body and had to be removed. If any doctor wants to insert a new material into you (and to me "new" means being on the market for less than 5 years), I would think carefully before agreeing. The same would apply, for different reasons, if a new drug has been out for less than six months, unless no other drug does what it does, e.g. oral Dabigatgran. And remember also that you may be able to tolerate a brand-name drug, but be allergic to the products that are use to constitute the tablet that contains the generic drug.

     What this means is that any new product implanted in your body is a potential time bomb, similar to the cardiac (heart) permanent pacemaker wires that broke inside the body after months of use, or the use of Xrays to treat childhood acne which  greatly increased their risk of developing thyroid cancer, or the rush of men to treat their prostate cancer with external beam radiation rather than surgery in the belief that this treatment lessened their chance of becoming impotent which has been shown not to be the case. When it comes to surgery, newer is not necessarily better, and we should not confuse the French work "neuf" with the French word "nouveau".Remember that the purpose of all advertising, including the advertising of medical services and products, is an effort to convince you to buy or insist on using the advertiser's product, just as in the 1920's tapeworm eggs were advertised and sold to women as a guaranteed method of weight loss.

     Finally, remember that the government always has its own agenda, and you might not know what it is truly looking for. To mention some of the more egregious government-sanctioned medical "experiments" on unwitting human guinea pigs (and Wikipedia can give you further information on each indicent) we have had (1) The Tuskegee experiment where Negro men in the USA were infected with syphilis without  being told what was being done, and with treatment then being withheld so the doctors could study the "natural" course of the disease, (2) The infecting of Guatemalan natives with gonorrhea, again without telling them what was being done to them, or offering any treatment (3) the testing of the efficacy of Birth Control Pills on females in Puerto Rico who were told that they were getting a free pill to prevent pregnancy, but  50% of the women received sugar placebos instead without being told of the substitution. I won't even mention the escape of nerve gas from the U.S.Army Proving Ground in Dugway, Utah that killed over 6,000 sheep, or the CIA putting LSD into the drinks of unsuspecting drinkers at bars in the 60's to study the effects of LSD on unsuspecting users.

     And be very careful about announcing that the (government) agent is wearing no clothes. In 1947 or so, a noted atomic physicist, Lewis Branscomb, was appointed head of the National Bureau of Standards, In the course of his government-directed studies, he conclusively demonstrated that an advertised additive did not extend the useful life of a car battery. He was subsequently hounded and persecuted by the Senator from the state in which the additive was manufactured.

   

What I Covered in a Patient's Medical History by Dr. Robin Motz

     I am continually surprised at the lack of depth and detail in many medical histories that I read that were in the charts of new patients. Of course I was trained at Columbia Presbyterian Medical Center in the late 1970's, and we were taught to allow at least a full hour for the complete history and physical of a new patient. I also have to mention that the last medical patient I admitted as an intern in June 1976 to ward 9W was a 19 year old female with new onset diabetes presenting as DKA secondary to an unknown infection. I examined her down in the ER, brought her up to the ward, and broke her DKA  20 minutes after I extracted a tampon I found on pelvic exam that  she had forgotten  she had inserted the previous month and was the source of her infection.

     We were also taught to come out and greet the patient in the waiting room and escort the patient back to our consulting room, rather than have the PA put the patient directly into the exam room.

     I would like to list here some of the questions that I find are often not asked of a patient on the initial exam by the new physician. This of course pertains to the office exam, and not to the ER exam. In the ER as I would tell my residents, the two main considerations are: (1) does this patient need a hospital admission, and (2) what disease or process can the patient have than can kill him/her before I come in to make my morning attending rounds  (and, in the case of females, ALWAYS do a pregnancy test). The following list is not exhaustive, but I believe that if the questions are not asked, the patient is not going to get the best possible medical treatment.

The order of the questions is usually unimportant, and their place on the list need not correspond to their importance.

1) Are you allergic to any prescription drugs? What was the reaction? (Important)

2) Are you allergic to any over-the-counter-drugs or vitamins or health foods?  What was the reaction?

3) Were you ever hospitalized for any allergic reaction and did you have to be intubated?

4) What prescription drugs do you take and what are their doses? What was the last one added?

5) Are you on birth control pills (many women do not think of this as a prescription)?

6) What daily vitamin and food supplements do you take?----dosage and frequency. ?Daily aspirin dose?

7) Have you ever donated blood? To the blood bank or prophylactally pre-surgery.

8) Have you ever received a blood transfusion? After an accident? or surgery? or childbirth?

9) Do you still have your gallbladder, appendix and tonsils? Any recovery problems or excessive bleeding?

10) Last TB skin test and AIDS test.

11) Last tetanus, pneumonia , and flu vaccine. .Vaccinated against hepatitis A,B; or HPV? MMR? one or two?

12) Have you ever had unprotected sex? More than once? What were the circumstances?

13) When you were a child, did an adult of either sex ever make inappropriate advances to you?

14) Any broken bones, or damages in a motor vehicle accident?

15) Any surgeries or transplants. If yes, any anesthesia reaction?

16) Date of last mammogram, pap smear, colonoscopy, chest x-ray, EKG, stress-test, bone density test.

17) Date of last eye exam. Can you read street signs at night? Are you fearful of night driving?

18) Where were you born, where did you live and go to elementary school, high school, and any college or further education. Any serious illnesses or fractures or sprains while growing up?

19) Have you ever been pregnant? How many times and how many births? Medical pregnancy problems---elevated sugar, elevated blood pressure, C-section. Current method of birth control.

20) How many siblings.

21) Illnesses that run in family. Causes of death and ages at death of parents and any first degree relatives.

22) Excessive bleeding after dental work or tooth extraction or minor surgical procedure.

23) Do you look forward to your S.O. coming home, or to coming home to your S.O.?

24) When was your last vacation?

25) Do you look forward to going to work?

26) Do you have ongoing problems with your parents or inlaws?

27) With your children?

28) If dog in the house, does dog get monthly protective  treatment against Lyme ticks? What other pets, and are they sick?

29) When was the last time you had sex with your S.O.,? Did you both enjoy it? When was the last time before that?

30) Do you have trouble falling asleep or staying asleep?

31) Have you ever consulted a psychiatrist or other mental health worker? Any prescriptions given?

32) Have you ever thought of committing suicide? If yes, have you ever actually made plans.?

33) If you have a health care proxy, who is the named person? If not your S.O., what is the difference of opinion that caused that?

34) Where do you see yourself 5 years from now? 10 years from now?

35) Is there anything you would like to tell me that I haven't covered, or ask me?

36) Have you ever traveled outside the continental U.S. If yes, did you get sick on your travels? If you traveled to a malarious area did you take the prescribed anti-malaria medicine and for how long?

37) Have you ever fainted or passed out? What tests were done if you did?

38) How many times a week do you exercise?

39) What was your weight at high school graduation? College graduation? Before first pregnancy?

40) Do you think you drink too much?

How to be a Healthier Patient

The list that follows is by all means not inclusive, and if any of you out there want to contribute to the list, please do so.

1) Please inform the doctor if you plan to (a) change the dose of a medicine or drop it entirely, or (b) not see the specialist to whom you were referred, or (c) plan not to do a suggested test.

2) Be aware of your family history. The risk of diabetes increases with age, and even more so if any relative has adult-onset diabetes and you are overweight. The risk for Alzheimer's Disease and coronary artery disease is also inherited. If either parent smoked and developed lung cancer, you shouldn't even think about smoking. If either parent or sibling had colon cancer, you should start colonoscopies at age 40, and have one every 5 years.

3)Feel free to search the internet about your disease, at the same time that you try to ignore the well-meaning advice from family members and friends. They may be angry with you for not asking for a different test, not getting another opinion, not seeing the doctor they recommend, etc.,, but remind them that it is your body, and it is more important to please yourself and feel comfortable with your medical decisions than to please them Discuss the internet results with at most one person. Once you have decided on a treatment plan, try not to second-guess yourself.
Never look up your symptoms, because you may imagine you have horrible diseases, as many second-year medical students do during their course in abnormal human pathology.

4)Be sure you have a signed and notarized copy of your pre-terminal and terminal wishes, and discuss this with your doctor and make sure both he and your medical power-of-attorney have copies.

5) Please make sure that your tetanus, shingles, pneumovax vaccines etc. are received at the recommended time intervals. (Vaccination is discussed in an earlier blog.)

6)You can be the best patient in the world, but sugar, cholesterol, and blood pressure all usually increase with age. By observing your doctor's recommendations, you can reduce the rate of increase of risk.

7)Avoid brand new "treatments" that only one doctor knows about. There are very few secrets in medicine, because all doctors want to cure their patients. If you hear/read about a new medical "development", you should wait for the second published paper. If it is an announcement after a talk at a medical conference, or shown on a TV talk show, then the results probably weren't reviewed at all. (Remember when a "study" claimed to show that coffee drinking increased the risk of pancreatic cancer? Or that lemon in hot tea in a styrofoam cup leached out a dangerous and carcinogenic chemical?) For that matter, they jury is still out on the safety of charcoaling meat, but no one seems to worry about this any more.

8) Please make sure your family doctor gets a copy of ALL your tests, both blood and Xrays, wherever they are done, especially including the emergency room. It is important for your health that at least one doctor has all your health records. (And if you want your doctor to use an electronic record storage system, I have received notices in the past 2 years from 3 Veterans' Hospitals that their system was hacked. Would you trust the fact that you are a married, bisexual, cocaine-using AIDS patient to the security of the internet?)

9) If you can, try to exercise non-stop for at least 30 minutes 3 times a week. The maximum exercise pulse rate is a myth. (Bjorn Borg's resting pulse when he won the French Open was 34, which is also typical of many marathoners.) You should exercise at such a rate that at the end of your workout you feel that you have exercised. Walking is great, swimming is a no-load exercise that shouldn't stress any joints, and if you use a treadmill, setting it on an incline leads to an unusual walking pattern.

10) If you want to lose weight, remember that no one stays on a fancy diet forever. Just use portion control, and be satisfied with a spoonful of chocolate ice cream rather than the whole pint. You burn fat when you feel hungry, so always leave the dinner table before you feel full. You don't even need a scale. Just feel how your clothes get looser. For a man, one belt notch, aka 2" around the waist, is about 10 pounds. If you are more than 100 pounds overweight and a diabetic, the most certain treatment to date seems to be gastric banding, but ask the surgeon how many he/she does a year. Also, remember that your metabolism slows down each year until you are about 75 years old, so if you don't reduce what you eat, you will probably gain 3 to 4 pounds each year. Just recall what you weighed when you graduated high school or college, or before you got married, or before your first pregnancy.

11) As of this date, there is NO evidence that treatment of prostate cancer saves lives (which doesn't mean that it does not, but only that there is no proof of its effectiveness.) However, I have never seen a wife who would let her husband not treat his cancer, so if you believe in "watchful waiting", then don't have the PSA test if you are married.

12) Please tell the doctor the whole truth and any and all complaints, whether the doctor asks you about them or not. Too many patients are embarrassed to discuss certain issues (is sex with your partner satisfying?), or do not raise certain complaints because they fear the possible diagnostic consequences. Too many men minimize their symptoms (men will almost always be macho with other men). Patients rarely discuss habits that they feel are demeaning or childish, or make them seem less than perfect in their own eyes or the eyes of their doctor. Remember that we doctors have really seen it all, both in our offices and in the emergency room, and we are not shocked, censoring, or belittling. We really do want to help you, and it is no longer true that an alcoholic is any patient who has a drink a day more than his/her doctor does.

13) Please only have protected sex. Too many of my college students don't. I tell all my female patients to keep a condom in their purse, don't tell the guy that you are on the pill, and that "if he doesn't put it on, he doesn't put it in".

14) If you are concerned that you may have AIDS or another sexually transmitted disease, then donate a unit of blood to the Red Cross. They will test your blood for AIDS, syphilis, hepatitis A,B,and C, West Nile Virus, and a few other disease, and the tests are run free of charge. Also, the country can always use another unit of blood, and there will be no record in your doctor's office chart for your life insurance company to wonder why you had an AIDS test.

15) Whether or not you have high blood pressure or diabetes, you should review your diet with a competent nutritionist.

16) For what it's worth, there have been at least two studies showing that women (but not men) who drink regular coffee decrease their risk of developing adult-onset diabetes.

17) Lastly, even the government now admits that daily (for men) and thrice weekly (for women) alcohol ingestion decreases the risk of coronary artery disease, heart attacks, and strokes. (See my previous blog for more details about the health benefits of alcohol.)

18) And you should probably see your doctor to review your health and be thoroughly examined once a year, but I know of no studies that support this suggestion.