storylines

Tuesday, October 5, 2010

The difficulty with watching football on television has nothing to do with the game or the number of advertisements. Instead, the proliferation of analysts that predict the storyline can change the way a fan watches a game. If the pre-game talk focuses on one player and that theme continues throughout the game, how can the fan at home appreciate the performance of the rest of the team? They are at the whim of those controlling the camera and the commentary.

That same bias also exists in medicine and it can make the patient-physician team veer wildly off course. Communication is the key to medical care. The physician has to understand the patient’s issues and situation and in turn, the patient has to try to explain as best as possible what is going on. Sometimes, though, the patient has already leapt to a diagnosis and the unsuspecting care provider may be taken along for the ride.

Certain complaints lead to that leap. People with abdominal pain worry about appendicitis; those with chest pain fear a heart attack. But there may be many other diagnoses that can fit those complaints and it may take lots of questions to get the answer. Interestingly, it is the story that the patient tells that focuses the physical exam and drives the tests that get ordered. It is up to the care provider to listen and then ask questions to get to the rest of the story.

The initial complaint opens a large list of potential issues called the differential diagnosis: what are the things that can go wrong in the body that can lead to the complaint. Gathering more information by asking question, performing a physical examination and doing tests shortens the list and may give the final diagnosis. But the storyline is the first test needed.

Patients don’t hide information on purpose, they just may not think that it is pertinent. Heart attack is the first thing that comes to mind when a person complains of chest pain and the medical community spends a lot of time and effort to get people to seek urgent medical care when they have chest pain. Too many people fear the diagnosis and hope that ignoring symptoms or attributing them to other ailments like indigestion will make them go away. It is the doctor’s responsibility to get inside the patient’s mind and understand the type of pain that they are experiencing. The differential diagnosis of chest pain may include many killer problems that the patient may not have considered. The physician (and in turn, the patient) can get burned by ignoring other killer diagnoses dissecting aortic aneurysm, pulmonary embolus, pneumothorax and pericardial tamponade. In fact, chest pain may not be come from the chest at all, but may be referred from other parts of the body. Gallbladder disease and ulcers can present with chest pain.

The differential diagnosis of chest pain can fill many pages, but it is important that the doctor avoid have a pre-game bias. Listening with an unbiased ear is tough and is made harder when the game plan differs from the patient’s expectations. The reality of medicine differs from what is shown on television. House and Gray’s Anatomy compress hours and days of care into less than an hour. The concept that time and observation provide diagnostic opportunity is often lost when the fear of the unknown persists in the room.

The communication skills of the doctors and nurses are key in explaining the whys and what ifs of the diagnosis and treatment plan. Tthe patient and the family are often too worried to listen to explanations the first time. It may take a couple of runs through the script to get the team on the same page. This problem is compounded by the patient being afraid to ask questions and to challenge discrepancies of fact. The give and take of this conversation can teach the doctor what is going on just as much as it tells the patient what to expect. If the story got lost or if the facts were misunderstood, the story may end up headed in the wrong direction.

The ability for both parties to understand each other makes for good medical care and that requires patients and care providers to keep their minds open to any and all possibilities. It is important to remove assumptions and bias from the patient care encounter and allow a free flow of information in both directions.

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