perception vs reality

 

The medical history can difficult to obtain for many reasons. A patient’s description of his illness can be affected by his perception of it, his experience with it, and what he imagines about it. By his expectations. By fear or denial. Or he may simply lack the language to express it.

“Perception is reality.”

~Lee Atwater~

For example, if I had to tell you what has been going on in my left foot for the past six weeks, I would be hard pressed to describe it. You would be left scratching your heads. It all started with localized pain during weight-bearing (but no tenderness to touch). It started to swell, and then, after four weeks, I noticed bruising. I don’t recall any injury. It’s hard to know what triggers the pain because it seems worse at night for some unknown reason. I have no idea why it is getting worse despite the fact that I have been faithfully resting my foot like I know I should. It frustrates me because I can’t exercise. It worries me, too. What if I need surgery? What if I can’t take care of myself?

Even though I’m a physician, and I know all about strains and sprains, overuse injuries and stress fractures, tendonitis and arthritis…I can’t really describe the discomfort. And because I don’t remember injuring my foot, I can’t make sense of it. This is weird.

Imagine how difficult it must be for patients to describe their symptoms or to make sense of their illnesses when they have neither knowledge, experience, nor language for what is happening to them.

“Write hard and clear

about what hurts.”

~Ernest Hemingway~

Most people are not used to thinking about their symptoms in the kind of descriptive terms physicians depend upon to narrow the diagnostic possibilities. For example, they might not realize that the difference between a headache that is generalized, dull and steady rather than unilateral and throbbing may distinguish a tension headache from a migraine. They may not be able to distinguish between the kind of pain caused by heartburn and myocardial ischemia. They might not use those terms to describe it at all. The patient is more likely to view his symptoms in terms of lost wages, his inability to provide for his family, or his own impending decline rather than the onset, character, and duration of his symptoms.

“Every sickness has an alien quality,

a feeling of invasion and loss of control

that is evident in the language

we use about it.”

~Siri Hustvedt~

Severity is especially tricky to assess. It depends to some extent on the patient’s innate tolerance for pain. Is he a stoic or a whiner? His perception of pain depends upon how his symptoms affect his mood, his ability to carry on, and his fears which are largely based on what he has heard, what he imagines, or what he has witnessed in others.

Take it from me, under the best of circumstances, the medical history can sometimes remain a mystery.

“One day I will find the right words

and they will be simple.”

~Jack Kerouac~

jan



you too?

 

*

 

 

...especially when your story involves a history of sexual assault.

 

Witness the proliferation of stories about sexual abuse that have corrupted America’s dignity over the past few years…beginning with the Church, then shaming the military and Hollywood, and now erupting at every level of government. Affecting even our Olympic athletes.

 

Witness the “me, too” movement rising from every corner of the country, voices that went silent years ago out of shame, fear, and guilt. Men and women alike.

 

The first time it happened to me, I was twelve years old. It happened again in high school and in college. Then in medical school. Then as a medical resident.

 

“People talk about sexual assault like it’s a

bad habit that men have.”

~Jon Stewart~

 

These were not just dates run amok. They were not consensual affairs. They were uninvited, unwelcome, intrusive encounters.

 

“It’s not consensual

if you make me afraid to say no.”

@hannahsnead5

National Sexual Assault Hotline

888~656~4673

 

I was lucky, though. None of these incidents was especially frightening or painful or traumatizing to me. In every case, I knew the person. They were all men who, until then, I had come to respect and admire…one, a relative. One, a fellow student. The others…physicians and colleagues.

 

The problem is I have no idea where these men ended up or what they are doing today. That means you might actually know one of them. Your child’s coach or teacher or pastor could be one of them. Perhaps one of them is your own physician, surgeon, or counselor.

 

Interestingly, we haven’t heard much about sexual assault among members of the medical community yet. God forbid patients should speak up. Imagine the stories they could tell...

 

“Our lives begin to end

the day we become silent

about things that matter.”

~Martin Luther King, Jr.~

 

jan

 

 

 

 

 

the best of circumstances, and the worst

 

 

 

Under the best of circumstances, it can be difficult for a health care provider to obtain a thorough and accurate medical history from a patient. Whereas the provider wants to hear about the onset, timing, severity, and nature of his symptoms, the patient may be focused on the fact that he had to miss work to keep his appointment, or that he can’t afford whatever tests or medications he may need. He may be ashamed to admit that he fell because he’d been drinking, or that he was coughing because he smokes, or that his sugar is high because he ran out of pills and can’t afford to refill his prescription. Or, he might simply have forgotten the details—for example, when his headaches first started, or how often he gets them, or what sets them off. All of which makes it hard to arrive at an accurate diagnosis.

 

“Diagnosis:

It is every doctor’s measure

of his own abilities;

it is the most important ingredient

in his professional self-image.”

~Dr. Sherwin Nuland~

 

And then there’s this:

 

We all have a friend or relative who can only be described as talkative. You know the kind-- mired in detail, obsessed with accuracy, insistent. A conversation with this person might go like this:

 

     Doc: So, when did the headache start?

 

     Pt.: It started last Tuesday. I remember because I had breakfast with my friend Barbara, and it started when I was driving home. No, wait. Maybe not. Maybe it was later that day, when I was in the grocery store. Or…did I go to the store on Wednesday? (pause) I don’t remember, but when I got home, I realized I didn’t have any Tylenol, so I took two Advil for it. Or…was it Aleve?

 

And so it goes, on and on and on in painstaking but inconsequential detail. And you only have fifteen minutes to coax the whole story out of this patient…

 

“Our lives begin to end

The day we become silent

About things that matter.”

~Martin Luther King, Jr.~

 

Or, you might meet up with this patient:

 

     Doc: I understand you’ve been experiencing some headaches.

 

     Pt.: Yup.

 

     Doc: When did they start?

 

     Pt.: A while back.

 

     Doc: Weeks ago? Months?

 

     Pt.: I guess.

 

You can’t pull a meaningful answer out of him if you kneel down and plead for it.

 

“I have learned now that,

while those who speak about

one’s miseries usually hurt,

those who keep silence hurt more.”

~CS Lewis~

 

In the first case, you wish you could shut the flood gates long enough to pull a few pertinent facts out of the overflow. In the other, you want to open the gates and net a few relevant answers before you move on.

 

The medical history challenges both of us, patients and providers alike. We’re in this together, and whether we are doing the speaking, or the listening, the correct diagnosis is our goal.

 

“Listen to your patient.

He is telling you the diagnosis.”

~Sir William Osler~

jan