Perhaps the Most Useful Question
a Doctor Can Ask a Patient
By Dr. John Briffa
I was interested to read the column of Dr Des Spence (a British general practitioner/family physician) in this week's British Medical Journal [Spence D. What happened to the doctor-patient relationship?]. He has chosen this week to lament the fact that modern medical practice has become more "tyrannical, hierarchical, controlled, intolerant, and dogmatic." There is pressure on doctors to 'follow the evidence' even though the evidence may be deeply flawed and biased due to considerable conflicts of interest. Another concern is the fact that doctors are remunerated for doing certain things, which can make it difficult for them to take a truly objective stance of some of what they do.
Patients who dissent and question or refuse treatment are openly scolded. There are many potential examples of this, but mammography and treatment with statins readily spring to mind.
The end result is that patients can end up being exposed to interventions for which there is little indication or evidence of benefit. Worse still, they can feel pushed or cajoled into things that they feel are not right for them. Dr Spence asks: "Are patients really getting the doctors they deserve?" As usual, Dr Spence demonstrates an ability to think for himself – a quality that is I think is not as widespread in medicine as one might imagine.
I think it's right that, as Dr Spence points out, doctors can sometimes do too much. However, it occurs to me that they can sometimes do too little as well. I have heard time and again from patients whose concerns and thoughts about their symptoms have been all-too-readily dismissed by their doctors. Here's a couple of examples:
A couple of weeks ago I was visiting a friend. She told me she had been suffering from a very sore tongue. I asked to look at it and it, to me, had the characteristic of what is sometimes referred to as 'beefy' tongue – dark red, smooth and shiny (quite like a piece of beef). This observation was helped perhaps by the fact that I know my friend has been vegetarian for 20-odd years, and for much of this time has been vegan. The relevance of this is that beefsteak tongue is a recognised symptom of B12 deficiency, and vegans (and to a lesser degree vegetarians) are at risk of this.
She went to see her doctor, and asked if her tongue issues might be caused by B12 deficiency. She told him about her dietary history too. Trust me when I tell you none of this line of thinking is implausible or illogical (if anything, the reverse is true). Her doctor's reaction? He said nothing. On looking at her tongue he said that she had oral thrush (a yeast infection) as a result of the steroid inhalers she takes for her asthma. She remarked that she did not take a steroid inhaler for her asthma, though. No comment from the doctor on this. She asked him what he thought of the idea that it might be B12 deficiency, and he replied that it wasn't that.
Now, exactly what caused my friend's doctor to put intellectual barriers up to her reasonable suggestion is unknown to me (and maybe him). One possibility is that he knows little about B12 deficiency and its signs, and does not want to make this evident (there's a tendency for doctors to 'be down on things they're not up on'). Another possibility, though, is that we doctors have a habit of liking to be the ones make diagnoses and be in control. Even unconsciously, we can reject ideas that come from our patients because, well, they have come from our patients (and not from us).
Another friend of mine was telling me recently about some bladder symptoms she was having. She had googled her symptoms and felt them to be a very good match with the symptoms of a condition called 'interstitial cystitis'. For what it's worth, I believe she made the correct diagnosis. She took her symptoms and a printout on the condition to her doctor. Her doctor would not entertain the diagnosis at all, though, and did not want to look at the literature. Instead the doctor told my friend that symptoms were coming from a scar from surgery from a long time ago (highly unlikely, in my opinion). Again, I have no idea what caused this doctor to reject an entirely logical and plausible potential diagnosis, in favour of something far less likely.
Particularly in the information age, individuals have much more access to medical information than they used to have. While doctors can be dismissive of 'Dr Google' I, for one, am not. The fact is patients often have more time and more motivation to research their health issues and arrive at plausible diagnoses. Whatever insecurities we doctors have about the fact that the patient may have made the right diagnosis (and not us) need to put to one side, I think.
In my experiences, patients are not infallible, but rarely do their ideas have no merit. Usually, they are highly useful. My personal view is that patients should be listened to when they offer their views on the cause of their symptoms. And even if they don't, my experience tells me that perhaps the most useful question a doctor can ask a patient is: "What do you think is going on?"