I have a split medical personality. On one hand, I am a pediatrician; I light up around babies and love to mess around with little kids. On the other hand, I am an Internist; I love complex problems and love talking to the elderly. But the one part of internal medicine which gives me perhaps the most joy is the opportunity to solve medical puzzles. Yes, pediatrics has puzzles in it too, but they are far more common in adults.
The term used for a medical puzzle-solver is diagnostician. It is always a great compliment to a physician to be called a great diagnostician. It means you are a good thinker, have a good store of facts, know how to organize your thoughts properly, and can see patterns in things you otherwise would never have found. It is the Sherlock Holmes, Lord Peter Whimsey, or Harry Dresden side of medicine. The diagnostician searches for clues, but especially searches where they are most often missed: right out in the open.
I am not sure anyone has called me a good diagnostician, but there are few things that give as much satisfaction in my job. It calls on my creativity, my memory, my mental organization, my ability to ask questions, my power of observation, and my ability to put all the disparate pieces together to form a cohesive whole. It’s not just coming up with an answer; it’s coming up with a plan.
This is also one of the sides of medicine that makes it mentally taxing. The simplest sounding problem may be something much more in disguise. “My baby has a fever” may mean nothing, or it may be Kawasaki’s disease or meningitis. “I have a cough” may be bronchitis (wink-wink), it may be lung cancer, or it may be the blood pressure pill someone was given a month ago. The important thing in approaching all of these patients is to do so with a process that is as consistent as possible. I try to go through every complaint, no matter how minor, using the same process. It’s always tempting to jump ahead and speed things along, but that is where the worst mistakes are made.
Here is the process I use when approaching a patient with a problem they want solved:
- Listen – I have to listen to what the patient says. How long has it gone on? What does it feel like? How long does it last? I have to pay attention to the details. Sometimes they will give the answer without knowing it, like when people say they’ve been tired for the past six months and then say that the neurologist started them on a medication, or that their mother died six months ago.
- Direct the dialog – it’s not just about asking the right questions, it is keeping the patient on track. Often they come in saying “I have a sinus infection,” or “It’s an asthma flare-up again.” I don’t let the patients pull me to conclusions for which I don’t have enough evidence. I re-direct them, asking them to only tell me facts about what they experienced. I want to hear the story as best as they remember it, asking questions to get out the things I think are most important.
- Believe the patient – Nothing makes doctors look worse than when we ignore what the patient says. I don’t accept the patient’s self-diagnosis, but not because I think they are lying to me; I just want to hear the story and see if I come to that conclusion as well. Patients are often very self-conscious about the story because it “sounds crazy”, “doesn’t make sense,” or because they don’t really remember things and think they will get it wrong. I do realize that people will get things wrong when they describe them, but that’s where my questions come in. I ask enough questions, clarifying where they are not quite sure and repeating things to make sure I heard it right. It’s OK that pain is hard to describe – it often is. I have no better source than the patient for the facts about what they experienced.
- Examine – The physical exam is just part of the data gathering put into the context of the story the patient tells. It is sometimes the tipping point, but it is the whole story in which the answer lies. A heart murmur means different things in a child, a pregnant woman, a man with acute chest pain, and an elderly woman with shortness of breath. The exam should be thorough, but also should be directed by the story. I examine people to get more puzzle pieces.
- Get more data – Family members are often helpful to give another perspective on things. Sometimes the patient has to come back several times before they remember a critical fact, or I ask the right question. I have to remember that sometimes at the first part of a movie or book, things seem confusing and contradictory, only to clarify as time passes and more facts are uncovered.
- Make a list - this is actually something I do through the whole process, and is one of the big factors separating good clinicians from bad ones. The list, known as the differential, has two parts: 1) What are the things that I must rule out? What is the worst thing this could be? and 2) What are all of the other possible things this could be? The differential takes imagination and relies on the diagnostician’s knowledge base of medicine the most. I usually don’t make a physical list, but I always make the mental list when listening to patients. Sometimes I can rule out serious problems just by hearing the story, but sometimes they require more testing.
- Address the fear – It’s very important for clinicians to remember that patients are often afraid. If they come to the office with headache, they are often wondering if they have a brain tumor or aneurysm. If they have chest pain, they wonder if it’s their heart. It’s not just good medicine to ask the question, “what are they afraid of?”, as the patient may be correct, it’s the key to the patient’s satisfaction with the care they get. It’s often that fear that caused them to come to the office in the first place. A person with arm pain may actually wonder if they are having a heart attack, as arm pain goes along with angina sometimes. It’s also important to know when the patient doesn’t have fear; they just need an excuse for work or school.
- Order the right tests – More is not better in this case. I don’t like confusing the issue by ordering unnecessary tests. A person with a bright red throat, a sandpaper-like rash, and a fever of 104 does not need a strep test. Getting one will either show what I already know, or I will ignore it because it contradicts all of the other facts. This is where the differential list comes in: I only order tests that will rule-out important bad diagnoses or strengthen the case for others. But tests are not meant to change what I know, they are meant to change what I do. I don’t order an MRI on everyone with sciatic nerve pain. That test is used for deciding if someone needs surgery or not. The best test for sciatica is to treat the presumed diagnosis with steroid and perhaps physical therapy. Those people who don’t respond to these treatments are the ones who might need an MRI.
- Look for patterns – It’s often the pattern that makes the diagnosis, not the symptom. Headaches that are episodic – that come on for a period of time and go away completely – are likely to be migraines. Symptoms like shortness of breath, chest pain, or arm/neck pain which happen when the person exerts themselves and goes away only with rest are suggestive of heart disease. Chest pain that lasts for a few seconds and then goes away, however, is almost never a serious heart problem. This is where the experience of the clinician is the most important, as well as their ability to get a good story from the patient.
- When all else fails, do nothing - As I said before, the diagnosis sometimes has to unfold over time. Doing nothing and watching to see what happens is very often the best thing (as long as serious problems are adequately ruled-out). If the mystery symptoms go away, then who cares what it was? Patients are usually OK with doing nothing if their fears are addressed, they feel that they’ve been listened to, they get a good enough explanation of the plan, and they have adequate follow-up. In other words, patients actually cooperate with doctors who communicate.
Gosh, this turned out to be longer than I expected. I really do love the detective portion of my job. I get to use my creativity and communication skills, and I get to comfort the anxious, answer questions, and sometimes uncover problems before they get serious.
Let me end with a bit of advice for patients:
- Tell your story first. If you have theories, tell them only after you’ve told the story, otherwise you may cause the doc to jump to conclusions.
- Don’t be ashamed if it sounds silly. You feel what you feel, and sometimes the strangest symptoms are the key to the diagnosis.
- Say why you came to be seen. What is the worst symptom and what do you fear the most?
- Don’t insist on tests or medications. More is often less. The best doctors, in my opinion, order less tests and give less medication than the worst ones.
- Get a plan. Understand what the plan of action is, and when you should call or come back in.
- Don’t ever assume. If you don’t get results, never ever ever ever assume “no news is good news.” Never. You got that? Never.
- Try not to be an interesting patient. It’s bad when you are a puzzle to your doctor. Words like, “man, that’s interesting,” or, “I’ve never seen anything like this before,” are usually bad signs. It’s even worse when you are presented in front of a group of doctors or are published in a journal. Don’t seek fame in this way. Stay boring.
P.S. That last one is tong-in-cheek.
Puzzle 1: Get your own Llama Puzzle Here
Puzzle 2: Yes, that is a puzzle of Michael Jackson with a llama. There are actually several of them shown here. No, I don’t understand.
Dr. Rob Lamberts is a primary care doctor, board-certified in Internal Medicine and Pediatrics. He blogs at Musings of a Distractible Mind.