AmyTuteurMD

AmyTuteurMD
Bio
Dr. Amy Tuteur is an obstetrician-gynecologist. She received her undergraduate degree from Harvard College and her medical degree from Boston University School of Medicine. Dr. Tuteur is a former clinical instructor at Harvard Medical School.

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NOVEMBER 19, 2008 8:36AM

Listen to your patient

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 “Listen to your patient, he is telling you the diagnosis.”

Sir William Osler

Those are the words of William Osler (1849-1919) often called the Father of Modern Medicine for his contributions to the development of medical education. I first heard them from the chief of surgery at the beginning of my internship. It is almost always true, the patient is almost always telling you the diagnosis, but listening is harder than you might think. That’s because most patients are simultaneously offering a lot of extraneous information, and some patients are not completely honest in the information they offer.

In fact, the patients who are deliberately deceptive seem to have an outsize influence on the practice of medicine. During internship and residency, young doctors are repeatedly fooled, and therefore embarrassed, by patients. Drug addicts are notorious for presenting themselves as model citizens with serious pain problems. After several episodes of unwittingly giving an addict a fix, or a prescription for drugs that will be sold, young doctors begin to listen to a patients’ stories with increasing cynicism. The subtext for many physicians, consciously or unconsciously, is that they must be convinced that the patient is telling the truth.

I suspect that this problem is at the root of many errors of diagnosis. It is obviously much more difficult to diagnose a problem if the patient has an unusually constellation of symptoms. However, the biggest stumbling block is that the doctor believes that if the symptoms make no sense, the patient must be telling the story wrong, or have some other reason for the symptoms such as depression or medication seeking behavior.

That’s the biggest advantage I have when approached by a friend or relative for help with a difficult medical problem. It can sometimes be much easier for me to figure out the diagnosis than it is for the doctor they are seeing. That’s because I start out by believing them, because I know them, and I don’t waste valuable time pondering whether they are honest or reliable reporters of their symptoms.

Recently a friend called me about unusual symptoms his father-in-law was having. The relationship between our families has extended through several generations, and I knew his father-in-law well. He is a distinguished emeritus professor with a piercing intellect and ongoing curiosity and engagement with the academic world. As he approached and passed his 80th birthday, he was afflicted with slowly progressive muscle weakness. He became wheelchair bound and continued to weaken even further. Ultimately, he was barely able to muster the energy to move.

His impressive team of doctors was stymied by the symptoms and took the easy road. They concluded that he was weak because he was old. There was nothing to be done.

His son-in-law called because his children were convinced that something was going on besides normal aging, but did not know what tests and investigations to insist upon. That’s where my advantage came in. I listened to his story and believed him because I knew him and I knew them. I started from the premise that the story must be true and went from there.

Whenever an elderly person develops a global symptom like fatigue or confusion, the first place to look is at their medications. As people become older, they are put on ever increasing numbers of medications to treat various unrelated ills. Often, some of those medications will interact to produce unusual side effects. In addition, as people age, the ability of the kidneys or liver to break down the medication and remove it from the body diminishes. Because the medication stays in the body longer, it has a chance to build up to toxic amounts. A dose of medication that was conservative 10 years before may have slowly become an overdose.

Since whole body muscle weakness is certainly a global symptom, I asked for a list of his medications, and then I went down the list looking for generalized muscle weakness as a rare side effect. I hit the jackpot almost immediately. Pravachol, a statin (cholesterol lowering drug) he had been taking for decades, is known to cause generalized muscle weakness in rare circumstances by damaging muscle cells. The chance of this unusual side effect is increased in the elderly and is further increased in people with diminished kidney function, which happened to be present in this case as well.

I was so excited that I called my friend right away to tell him. I promised to do further research later in the evening, but in the meantime, he started investigating the rest of the list for unusual interactions between drugs. Sure enough, he found that another medication on the list was known to interact with Pravachol to increase the risk of generalized muscle weakness.

We had the diagnosis: Pravachol induced myopathy exacerbated by age, decreased kidney function and interaction with another drug. My friend called his father-in-law’s doctors first thing the next morning, and the Pravachol was discontinued. Recovery began almost immediately. He now feels better than he has in years and has begun to walk again.

The professor called me recently to express his gratitude. He thought I had made an incredible diagnosis. Frankly, I am a bit embarrassed. I didn’t really diagnose anything. He had been recounting the symptoms of statin induced myopathy in detail for months, if not years. All I did was listen.

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Great post, Amy.

Medications are also the first thing to look at when elderly patients begin tripping and falling on a regular basis.
Kudos Doc. Listening is the lost art form in the world today. I think our President is a prime example. He doesn't listen to human beings or the country, he only listens to God who speaks to him directly.

Not to be blasphemous as I am a believer in God (c'mon Frank, give me a break please) but Dubya believes God talks/"conversates" with him.

People in all professions just DON'T listen any more. No other professions require consummate listening skills more than a Doctor. Our lives depend on it. Literally.

Rated
I'll have to keep this in mind as I get more jaded :)
Impressive call by the OB. :) Good job. What was the other drug??
Amy,

You must be a great Dr.

Interesting, what you describe is very similar to what I experience as a teacher helping young students through the process of writing--if I allow it, they will perform their own diagnosis simply by talking it out. Usually when they come to me with a "sick" paper, I just ask a lot of questions; we normally vet it out without even looking at the draft.
Ann Rhys Matthews:

"Medications are also the first thing to look at when elderly patients begin tripping and falling on a regular basis. "

It's a good idea for any elderly person, or a child or friend, to periodically review all medicines with the primary doctor. Because many elderly people have multiple doctors, they may be taking medications that interact with each other, without any doctor being aware of it.
G.T. Randolph:

"People in all professions just DON'T listen any more. No other professions require consummate listening skills more than a Doctor. Our lives depend on it. Literally."

That's why it makes no sense to push doctors to see more patients in less time. They often cannot think about any one patient long enough to make the diagnosis of unusual diseases or side effects.
pontificatrix:

"What was the other drug??"

It was an antifungal medication.

That's ironic because the antifungal was necessary to hold in check another unusual disease that the professor had that was originally misdiagnosed --- a fungal meningitis.
k1mjaye:

"You must be a great Dr."

Thanks. I'd like to think so, but I'm not sure that this is an example. This was just geriatric medicine 101: always start by looking at the patient's medications. I still can't understand why his own doctors didn't do that.
Great post! I can't tell you how many doctors, and their office staff for that matter, could benefit from this advice. A few years ago I was scheduled for a colonoscopy but called to reschedule because I was sick with the flu. I cannot tell you how difficult the office manager I spoke to was about rescheduling my appointment.
"Well, he is a doctor you know, you should keep the appointment if you feel sick."
"Why would I travel an hour to see my gastroenterologist for the flu when my GP is a block away?"
"Well it's going to be months before we can reschedule you. You should really just keep the appointment."
"I am in no condition to be taking laxatives and enemas to prep for the test, I'm too sick." And then he actually said to me
"Right, because you know your body better than a doctor could." At that point I hung up and called back later to speak to someone else (who rescheduled me without incident for the following week). True, doctors know THE body better than their patients- they have (or should have) a more thorough understanding of anatomy and the general stuff- but when it comes to the details only the patient can provide those. The patient has a better idea of their limitations, their level of pain, etc. Therefore, doctors and patients should act as a team, and sadly that doesn't seem to happen enough.
Thanks again for a great post!
Imagine how long it took for them to diagnose Lupus in my case. I had to be the so called squeeky wheel. Lupus represents itself in so many different ways that if I hadn't insisted on some marker tests then I am not sure the Docs would have caught it. Please, communicate honestly with your doctor. They are human too. Now my problem is, I can't get them to listen to other complaints because they chalk it up to the Lupus no matter what it is. I am not giving up though :).
M. Allison Anger:

"Well it's going to be months before we can reschedule you. You should really just keep the appointment."

Don't even get me started on the problems with office staff. A friend of mine who is an oncologist called me to related her horror and amazement at how one of the secretaries treated a patient. The patient had come for a routine appointment to monitor how she was doing with chemotherapy for breast cancer. When she checked in a the front desk, the secretary actually said: "What happened to your hair? You used to have such beautiful hair." The patient promptly burst into tears."
BeverlyJRaffaele:

"Now my problem is, I can't get them to listen to other complaints because they chalk it up to the Lupus no matter what it is."

That is a very serious and all too common problem. Partly it happens because all doctors are taught the principle of "Occam's razor," which is that the simplest explanation is usually the best. Attributing new symptoms to an ongoing disease is usually the best explanation. However, the key word is "usually." Sometimes there is something else going on, and a doctor ignores that possibility at the patient's peril.
Oh, dear. Just one day after saying elsewhere that I was not interested in following your posts ever again, here I am checking out what you have to say. A newcomer not only to OS but also to this form of on-line community, I feel like a kid in a candy store, endlessly distracted by one goodie after another.

So here you are giving us a window into a doctor's world, complete with observations that could give ammunition to those who are disposed to find many doctors obtuse and isolated in their insular sphere.

I am a nursing student. I come to this pursuit relatively late in life. I've spent a lot of time as a cog in various corporate machines, as a freelancer in areas high tech and white-collar, and as the lowliest of manual laborers. I've seen the working world from a many different angles. I think I am an outlier in this regard.

Submerged as I am now in the orthodoxy of nursing school and in fulfilling the clinical role of a nursing student, I not only see the medical system from the inside now but I bring a wide-ranging and somewhat jaded level of experience to it.

What you did for your friend was excellent. It epitomizes the highest ideals of our paradigm of health care. I just want to say that I feel that I have been taught the same skills that you used to discover the true nature of your friend's problem. As you point out, the research you performed was not particularly sophisticated. I wonder, though, whether your friend's doctors would have been as receptive to hearing those conclusions from someone like me.
Dan O'Brian:

"I wonder, though, whether your friend's doctors would have been as receptive to hearing those conclusions from someone like me."

A good nurse is an invaluable asset on any medical team. A bad nurse is a disaster and a danger to the patient. Any doctor is glad to collaborate with a nurse he or she can trust. Dealing with one who doesn't know what she or he is doing is a disaster for everyone, particularly the patient.

The bottom line is that if you do your work in the trenches and emerge with good skills and sound judgment, you will be a valuable part of any team.