Monday, February 13, 2012

Why Have We Stopped Listening To Our Patients?

Today, I heard a compliment which came completely unexpected. A patient told me “doc, you are the fourth one I have visited for this problem and you are the first one who asked me what my problem is and waited for me to say it. The others just told me what my problem is and what they were going to do about it” this was completely surprising to me. For I had been taught that listening to the patient or taking an history as we call it is the first step to diagnosing on every medical course I have attended. It is has been drilled again and again that I was literally surprised that people are not doing it anymore. And then on second thoughts I thought I understood why. There has been a tremendous explosion in the field of medical investigations recently and doctors have so much of data and information on their hand even before they see a patient that its literally possible to just read the reports, go through with further investigations if needed, diagnose and cure a patient sitting at home without ever touching them or even seeing them.

But I had been trained by Dr.Murugesan, General Physician of Madras Medical College, long, long ago, that the best diagnostic devices are your ears and hands. The man was a magician with his hands; he literally prodded and pinched his way to diagnosis. He taught me the four cardinal diagnostic techniques- inspection (look at the patient), palpation (use your palms to feel the area), percussion (use your finger-tips to percuss for resonances) and finally auscultation (using a stethoscope to hear). But preceding all this was the fact that you had to listen to your patient’s complaints- that came first. He used to imitate the walk of patients with certain diseases and have us judge which patient had which disease just by the gait. He had us smell the patients breath to try and identify the odours and the diseases causing them. And palpation of the organs was his specialty- he taught me to differentiate the gall bladder/liver diseases and how in an ascites patient the fluid rolled from the stomach with change of posture and how you can just pock a finger into a swollen ankle, check for fluid dependency by how fast it took to fill up and then diagnose a hemodynamic imbalance/hypertension/failing kidneys/cardiac disease- and all by poking a finger. I bet even the latest 64/128-slice cardiac angiograms would never have been as fast as him.

The problem with my patient today was that she gave a very specific history of Streptococcal sore throat – with all the classical presenting symptoms like fever, sore throat, glandular swelling and especially Odynophagia- burning sensation in the throat on ingesting anything. It’s a failry standard disease with broad spectrum antibiotic therapy as first line treatment. But the others had dismissed the patient with a “uh! It’s a common cold, go take some anti-histamines and steam inhalation”. I was a little in doubt with my own diagnosis when the patient told me this- three stalwarts off the profession versus newbie me? Fortunately I had a Medscape App on my smartphone and I confirmed my diagnosis with WebMD. There it was on the very first line Odynophagia=strept throat. Fully reassured, I came back from the pretext of getting water to drink which I used to leave the patient alone for a minute to check online and with confidence restored in my diagnosis, handed over a prescription for a broad spectrum antibiotic and advised her to come definitely for review after the mandatory 5-day antibiotic course.

The point I am trying to make does the fact that we have superior technology really excuse us from using our ears to what the patient really wants to tell us? I know that some of us are rally busy practioners and a lot of patients have this tendency to ramble along on multiple tracks confusing us with multiple diseases all at the same time (for a single fee…), but can’t we just prod them along the right path to stick to the primary disease in hand? Instead of switching off completely form them and letting them feel that we are just not interested in what they have to say? I mean you can even charge them for “listening time”. But why don’t you give them a chance to say what they really want to say to us? It’s their disease not ours and they know it better, don’t they? They literally live with it. We just offer a opinion and get paid for it to boot. where is your sense of mystery and excitement? Are we that jaded in our professional lives? Are we too turning into diagnostic machines?

I wish my readers would really help me out on this with their suggestion and advices…

1 comment:

  1. I guess lack of time is the primary reason for this. In my view I think the situation would improve only if the doctor to patient ratio decreases and we have more time to get into the detailed history taking. I have often experienced that even if the history taking does not aid in diagnosis just talking to the patient about the illness makes them feel better and helps in developing a good rapport with them.