True story:
A patient of mine presented to the office concerned about unexpected weight loss that had started a month or so earlier. She had no other symptoms. She told me she was eating normally. She had no complaints related to her GI tract...no nausea or heartburn, no diarrhea or bleeding...and no swollen glands or fever that might lead you to suspect something more systemic. Initial labs were normal, including her blood count, electrolytes, sugar, liver and kidney function, and thyroid. I ask her to keep a food diary for a couple of weeks. When she returned, her weight was still going down despite an adequate caloric intake. I proceeded to go through the screening questions for eating disorders, depression, and drug and alcohol abuse, but came up with nothing. The diagnostic process went on for over six months. During that period of time she underwent a full GI evaluation. She saw an endocrinologist. Finally she ended up seeing a psychiatrist who, because he was part of the same health system and used the same EMR as we did, went through the same set of questions, checked all the same bullets, and came up empty handed, too.
"I was depressed," she said. "I just didn't realize it."
Wait a minute. I had asked her about depression. The psychiatrist had asked, too. We'd asked if she'd experienced loss of interest in doing things, feelings of hopelessness, sleep disturbance, fatigue, or change in appetite. The list went on. She'd answered "no" to every question, because that wasn't how she experienced her depression. She was feeling shame. Anger. Abandonment. None of which appeared in the EMR.
So how do you get around this? How can you get to the truth?
Rita Charon, professor of medicine, and founder and director of the Program in Narrative Medicine at Columbia University College of Physicians and Surgeons, begins every patient interview with one open ended prompt. She invites the patient to:
Then she listens.
This approach opens a portal to the patient's story. It permits the patient to share whatever she knows about her illness, in whatever words she chooses to use. It enables her to tell her truth. My patient might have been spared months of diagnostic miscues and a fortune worth of tests had she been able to tell her story in her own words.
When things don't add up, when you can't arrive at a diagnosis after exhausting every avenue, when you start to feel frustrated, you might try starting over again. Ask the patient what he knows. Start with the first line of the first paragraph of the first chapter of his story.
A patient of mine presented to the office concerned about unexpected weight loss that had started a month or so earlier. She had no other symptoms. She told me she was eating normally. She had no complaints related to her GI tract...no nausea or heartburn, no diarrhea or bleeding...and no swollen glands or fever that might lead you to suspect something more systemic. Initial labs were normal, including her blood count, electrolytes, sugar, liver and kidney function, and thyroid. I ask her to keep a food diary for a couple of weeks. When she returned, her weight was still going down despite an adequate caloric intake. I proceeded to go through the screening questions for eating disorders, depression, and drug and alcohol abuse, but came up with nothing. The diagnostic process went on for over six months. During that period of time she underwent a full GI evaluation. She saw an endocrinologist. Finally she ended up seeing a psychiatrist who, because he was part of the same health system and used the same EMR as we did, went through the same set of questions, checked all the same bullets, and came up empty handed, too.
"Histories must be received,
not taken."
~Sir Richard Bayliss~
The patient must have given up on me because I didn't see her again for over a year. When I did, she had regained her weight and appeared healthy and strong. I asked her what had happened. What had caused her weight loss and how she'd recovered from it."I was depressed," she said. "I just didn't realize it."
Wait a minute. I had asked her about depression. The psychiatrist had asked, too. We'd asked if she'd experienced loss of interest in doing things, feelings of hopelessness, sleep disturbance, fatigue, or change in appetite. The list went on. She'd answered "no" to every question, because that wasn't how she experienced her depression. She was feeling shame. Anger. Abandonment. None of which appeared in the EMR.
So how do you get around this? How can you get to the truth?
Rita Charon, professor of medicine, and founder and director of the Program in Narrative Medicine at Columbia University College of Physicians and Surgeons, begins every patient interview with one open ended prompt. She invites the patient to:
"...tell me what you think
I should know
about your situation."
~Rita Charon, MD, PhD~
Then she listens.
This approach opens a portal to the patient's story. It permits the patient to share whatever she knows about her illness, in whatever words she chooses to use. It enables her to tell her truth. My patient might have been spared months of diagnostic miscues and a fortune worth of tests had she been able to tell her story in her own words.
When things don't add up, when you can't arrive at a diagnosis after exhausting every avenue, when you start to feel frustrated, you might try starting over again. Ask the patient what he knows. Start with the first line of the first paragraph of the first chapter of his story.
"The good physician treats the disease;
the great physician treats
the patient who has the disease."
~Sir William Osler~
jan
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