I had a remarkable experience recently. A woman who came to me described her symptoms so perfectly, I felt I was reading a textbook or answering a board question. She even used the phrase “like a vice around my head,” which is a classic description of a particular type of headache. I raised my eyebrows and asked her if she looked up her symptoms. To my amazement, she denied it. After that mini-interruption, she went on to describe things that made it worse and better, how long her symptoms were present, and what recent changes had occurred that may be contributing to her current symptoms. In just a few minutes, after a thorough exam and a few other questions, the diagnosis was clear. I told her what it I thought she had and how to treat it.
So, what was so remarkable about this interaction? It seemed to good to be true. This woman followed my outline for telling her story without ever having read my blog. In doing so, she made my job much easier and her evaluation cost-effective, low-risk (No CT scan needed), and with minimal pharmaceuticals (if she alters her surroundings a little).
This led me to wonder: Why is this type of interaction so rare?
So much of what is necessary for making a diagnosis is the history. Contrary to popular understanding, the way a patient tells his/her story dictates the next step. The answer is not always revealed by testing. There are likely to be more false positives when obtaining a battery of tests based on a poor history than in appropriate testing with a thorough history. Of course, the onus is not on the patient alone. It is the physician’s job to conduct the interview (as nicely described by Dr. Vertabedian).
Sometimes, patients seem to tailor their histories to fit certain endings, throwing in various phrases that may suggest a particular diagnosis. I suspect this is a byproduct of “researching” symptoms online. As is the case when telling a story to fit a particular ending, there is a lack of flow and cohesiveness, but more deliberateness in the execution. An astute physician would be able determine what the patient is most worried about by the way the he/she is giving his/her history. More often than not these days, I find myself asking the question, “What do you think might be the problem?” In truth, most patients hesitate and do not want to presume to make a diagnosis. But with a little persistence on my part, they might say, “brain tumor” or “heart attack” or “cancer.” What often happens at this point is that I spend a significant amount of time clarifying whether or not what they say really fits what they are experiencing or if they have been influenced by their worst fear.
The internet, a double-edged sword, provides easy access to information, but a certain level of acumen is required to integrate and sift through the enormous amount of accurate and inaccurate data on the web. While providing real-time access to useful information for both patients and physicians, the internet is also creating a new type of medical history-taking. One in which a patient’s perceived diagnosis may be the most integral component of the history.
Of course, there are patients who come up with accurate diagnoses. This is not as common as one would think, however. At this time, typing in symptoms into Google does not take into account the suggestibility of humans.
If not happening already, medical education will need include this new type of history-taking, one that recognizes the evolution of the patient as potential diagnostician and how this affects his/her own perception of symptoms.