patience is a virtue

Monday, June 20, 2011

In golf, patience is a virtue for both the athlete and spectator. A pro tournament plays out over 4 days and there is no way to make that last hole on Sunday come any faster. Even if one player is well ahead with winner almost assured, there is much to be appreciated and enjoyed watching the events unfold on the course. The latest testament came this weekend as the golf world waited for two days to watch Rory McIlroy win the US Open championship. The event had little drama as the inevitable leader maintained an insurmountable lead. The same inevitability can be said for the practice of medicine. Too often, patient and families presume that the speed of medicine approaches that seen in television programs like ER and House, where days of work are crammed into 45 minutes. The real world creeps much more slowly.

The world of medicine is filled with technology that can peer inside the body and help make a diagnosis but perhaps one of the most important tools that gets very little respect in today’s fast paced environment is observation. Too often, patients don’t allow time to let symptoms progress or resolve and frustration can arise when the physician wants to take time to watch. In today’s fast paced world, the concept of slow is a hard sell.

Diagnosis usually begins with the history. The story gives direction and most often provides enough information to make a diagnosis. The physical exam corroborates the story, confirms suspicions and allows the diagnosis to be made. Lab tests and imaging like x-ray, CT and ultrasound can make the diagnosis more certain. Each has a potential role to play but the results need to be interpreted in context. This is where time and patience come into play. Some patients believe that the secret of diagnosis is in technology and more is better. The truth is that tests have their limitations and should they be required, timing is everything.

When an otherwise healthy patient presents with abdominal pain, there is often the unasked question or fear whether the cause of the pain is appendicitis. Years ago, that diagnosis was made clinically. The doctor asked questions, felt the abdomen and checked a white blood cell count. If appendicitis remained a reasonable concern, the patient was taken to the operating room where an error rate of up to 20% was deemed acceptable. One did not want to miss the diagnosis of appendicitis, so some patients with a normal appendix ended up on the operating room table. The process was relatively quick. Then came technology and the ability for CT to peer into the body and the whole process slowed down.

History, physical exam and blood tests led to the consideration of appendicitis as the diagnosis but if the surgeon wasn’t completely convinced, imaging is ordered. Sometimes an ultrasound is step one and if the appendix can be identified as normal or not, the story ends. However, ultrasound may not be able to find and identify the appendix. CT may be the next step. However, the patient needs to have had symptoms for at least 12 hours since it takes that long for the CT scan to show the inflammation of appendicitis. Do the scan too soon and the doctor may be fooled into thinking all is normal when it isn’t. Some radiologists are comfortable reviewing a CT for appendicitis without oral contrast (a drink that helps outline the intestine) but others demand that the patient drink the contrast fluid over60-90 minute time frame. Also remember that the radiologist may take a half hour or longer to review the hundreds of images. The ability to look at the appendix and come to a diagnosis may take a couple of hours from the time the test is ordered. So much for getting results within the 45 minutes it takes on House.

Patience is an important diagnostic tool that patients need to embrace. Time allows symptoms to declare themselves for better row rose. Sometimes there are true emergencies where seconds and minutes count but more often, time is the ally of the patient and the doctor. Awaiting the inevitable doesn’t always happen. Ask Mr. McIlroy, the same person who coasted through the US Open, whose golf skills evaporated on the final day of the Masters turning his inevitable win into an inevitable loss.

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