Patients Lie. Why Doctors Should be Like Medical Students. A Good History is a Checklist.

The most common question first year medical students ask me is how do they become efficient at taking a patient history.  Can they skip certain parts of taking the patient history and avoid asking about a social history, whether a patient drinks, smokes, uses drugs, or is sexually active?  When can they stop asking about the review of systems, a list of questions asked about each organ system?  A comprehensive history is used in the emergency room, hospital, or during an annual physical, not in urgent care or an outpatient appointment, right?

Wrong.


Patients lie and don't even know it.  It's not that they mean to.  In fact, they are trying to be helpful when giving a history of their symptoms.  Medical students concerns about taking a fast history reflects two things.  First is the reality of the limited amount of face time with patients, which unfortunately seems to be even less than the past.  Second, more importantly, is their fascination and desire to get started on real medicine -- what are the diagnoses, treatments, and tests that must be learned to be a good doctor.


In fact, what they realize after working with me is that the most important part of being a doctor is talking to patients and listening.  Taking a good history is the essential part of being a good doctor.


Here are two examples of patients who I saw during the winter.  The practice is busy this time of year.  I'm often running late.  Like many encounters, I've never met these patients before.  In many ways, it can feel like an urgent care practice.  Which patient is lying?  Can you tell?

Young woman wanting a work note for the flu.  She was complaining of a three day history of diffuse muscle pains, headache and high fever.  That's it.  She had no other concerns.  Just anxious to get home and go to bed.


OR


A young man with an ankle injury after playing soccer.  As an aside, he also asked about stomach flu which occurred a few days prior.  He had nausea, abdominal pain, and vomiting for a day.  He still had abdominal pain.

Which one was lying?  Both.

A medical student or doctor recently out of training might have not missed the diagnosis in either patient because they are still working on how to hone down their questioning.  In other words, they haven't take the shortcuts yet and still ask comprehensive histories.  Yet, they aspire to just ask the vital questions to be efficient.  A more seasoned doctor who is stressed and busy may have taken mental shortcuts and moved on.

In other words, how do you know what is and isn't vital until you ask?

Patients also have fallen into this trap believing this tradition of talking to their doctors is simply unnecessary, worthless, and an obstacle to getting to the truth.  With increasing out of pockets costs for office visits, I'm seeing more requests from patients to simply get a MRI or blood test instead of seeing a doctor not only to address the problem, the real reason for the tests, but also if testing is usually necessary (it isn't in the vast majority of cases).

A good history is very much like the checklists pilots use and what Dr. Atul Gawande advocates in his book.  Taking a good history also slows doctors down and allows them to avoid cognitive errors (as described beautifully in the book How Doctors Think), think more clearly, and avoid jumping to premature conclusions.  Even the time honored skill of thinking through a differential diagnosis and thinking hard to make a long list of possibilities is a checklist and safeguard to consider other alternative problems that wouldn't appear when stressed.   Being a doctor requires thinking and less knee jerk responses. 

So what did the two patients have?

The first patient didn't have the flu.  She had a kidney infection known as pyelonephritis.  In taking the review of systems when asked about her urination pattern, she realized that it had changed during her illness.  Also, in asking questions, she had no other signs of having a upper respiratory illness, no cough, no runny nose, no head congestion.  Instead of simply writing a work note for a presumed virus and moving on to the next patient, this patient received antibiotics.  Untreated, pyelonephritis can be serious and require IV antibiotics or hospitalization.


The second patient didn't have stomach flu.  In fact, patients also make similar mental shortcuts by telling us what they think is going on - "stomach flu" rather than telling us specific systems.  When people refer to stomach flu, like food poisoning, often there is nausea and vomiting which then is followed by diarrhea.  He didn't have diarrhea just persistent abdominal pain.

He had gastritis, irritation of the stomach lining, due to alcohol abuse. Asking about his social history, he admitted to binging on a 12 pack of beers that day, a behavior, not uncommon for him.  Not only was he treated for this, he was also recommended to quit drinking.

So even experienced doctors can take a page from medical students.  It's the taking the history that matters.  Everything else we do, the physical exam, lab work, and imaging tests are tools and not the truth.

Want to know, one other time a patient lies?

When you see an otherwise healthy young man in the office who simply wants an annual check-up just to be safe.  These types of patients are as common as seeing the Loch Ness monster.

The real reason he's there?  His spouse, girlfriend, or significant other for a symptom he's been complaining about but didn't want to see a doctor.

If I don't get to that truth, guess who I'll be seeing next week?  The same patient again but with his spouse, girlfriend, or significant other.


Or he's asking about Viagra.

Prescribing Placebo Treatment Study Is Flawed and Misleading

A recent study suggested that doctors common prescribe placebo treatments and that this behavior is considered ethically permissible. The article received a lot of press. Pity that the study is terribly flawed and misses the point.

Researchers admit that the behavior of doctors recommending treatments that weren't proven to be helpful (i.e. antibiotics for colds, which are caused by viruses and therefore can't be killed with antibiotics) was best captured by the world "placebo". Very misleading. The problem is that placebo "is a substance or procedure a patient accepts as medicine or therapy, but which has no specific therapeutic activity. Any therapeutic effect is thought to be based on the power of suggestion." Antibiotics do have therapeutic activity, just not against viruses, and can cause major side effects.

Doctors don't write prescriptions for antibiotics for the placebo effect. They prescribe it because patients demand it and to ensure that patients come back again, doctors feel pressured to comply. Research shows when patients demand advertised medications, more often then not they get exactly what they wanted. Unlike the conclusion of this study, many doctors felt ambivalent that they wrote the medication.

Saying that recommending over the counter analgesics is also a placebo is also a problem. These actually do have therapeutic effects like decreasing pain or fever. As the researchers found practically no one prescribed sugar pills.

Doctors are prescribing antibiotics and sedatives for conditions which they might not help, not because of the placebo effect, but because patients demand something be done and the offered therapies probably won't cause harm (and the doctors simply want to avoid a confrontation or discussion of why no therapy would work), doctors aren't practicing evidence-based medicine (the vast majority of sinus infections - sinusitis and bronchitis in healthy individuals does not require antibiotics and vitamin b12 injections don't help with general fatigue), or doctors just want to do something. In all three scenarios, potential harm can occur.

This is contradictory to the meaning of placebo and why the study's claim is so flawed and misleading. As the authors noted, "Few of the physicians we surveyed recommend inert placebo treatments. " i.e. pills that do nothing, like sugar pills. Why? Because unlike other cultures, like Israel where doctors about a third of the time do prescribe sugar pills, placebo treatment is not considered acceptable treatment.

Claiming that doctors commonly prescribe placebo treatments and are ethically fine with it is wrong. It is a shame that the media didn't have the level of sophistication necessary to dissect this out.

Why Patients See Us

It often takes a little illness to remind doctors what it means to be patients. At least for me. Coming home from work a few days ago, I came down with a sudden feeling of profound fatigue, muscle aches, and chills. While initially I thought it was due to inadequate sleep, it became more obvious as I began coughing up greenish phelgm and increasing pain in all of my muscles particularly in my low back and eyes.

I stayed in bed the entire day only getting up to eat a small lunch or dinner. I don't particularly like taking medications (most of my patients feel the same way) and refused to do so. It's a viral illness. It will get better.

If I wasn't a doctor, I suppose I might think it was something more serious. But my training told me that with no high grade temperature, no wheezing, no shortness of breath, it most likely was a cold. Nevertheless, it didn't make me feel any better knowing this.

So this is why patients look as us incredulously when we tell them it is a virus and there isn't any special medical treatment besides time, rest, and some over the counter medications. My family members in the past have been offered antibiotics and even prednisone for clear cases of viral illnesses. Although the well meaning doctors and nurse practioners probably felt that patients would feel better that they would be doing something, educated patients know that this behavior in fact this is not appropriate and not only drives up healthcare costs but also antibiotic resistance.

As I try to reassure myself that the periodic coughing of phelgm, the constant muscle pains and chills will pass, my better half encourages me to try some Tylenol. Tylenol? After I became a doctor, I've become more reluctant to take medications. But, really, Tylenol?

After 1000 mg of Tylenol and an hour later, I felt quite a bit better. Although I am still recovering, it just goes to show that the best medical treatment is understanding how someone else feels by being put in his shoes and the compassion given, as well as time, over the counter medication, and rest, is all one needs to get well.

Antibiotics Aren't Necessary

Not a surprising report, except perhaps to many patients, that antibiotics aren't generally needed for sinus infections. Earlier this year the professional society of otolaryngologists, that's ear, nose, and throat doctors, had a similar statement. Sinus infections generally are caused by viruses. Those infections that need antibiotics are often those where a head cold was improving and then suddenly got worse.

Don't be shocked if your doctor doesn't prescribe antibiotics before for something which was done in the past. With more resistant bacteria, like MRSA, it is important that we save antibiotics only for conditions that require it. If you do get antibiotics, finish it completely even if you are feeling better. Not completing a full course of treatment is another cause of increasing bacterial resistance.

With all of this knowledge, don't you feel better already?

Vaccine against "infant killer"

Doctors in Macau, which is near Hong Kong, want the government to pay for the pneumococcal vaccine to protect against Streptococcus pneumoniae. The bacterium dubbed "infant killer" claims nearly 50 children per hour in Asia. The bacterium is already resistant to many antibiotics. Unfortunately the cost of the vaccine is out of reach for many in Asia.

Lui Kin Man, president of the Macau Paediatric Society, said childhood vaccination against the bacteria was important in southern China because treatment was especially difficult.

"In our region, like Hong Kong, Macau and Taiwan, bacterial drug resistance is very high, and pneumococcal (bacteria) is resistant to drugs like penicillin and erythromycin," Lui said in a telephone interview.

"Mortalities (caused by the pneumococcal bacteria) are higher in developing countries and mostly from pneumonia. Of all pneumonia deaths, 40 percent of them are caused by this bacteria," Lui said.

In the United States, prior to the development of a vaccine that protected against Streptococcus pneumoniae, the bacteria annually caused over 700 cases of meningitis, 13,000 cases of blood infections, over 5,000,000 ear infections, and 200 deaths in children under five from invasive disease.

In America, children are routinely offered this vaccine. Recommendations by the Centers for Disease Control suggest that for children, the vaccine is a series of shots given between the age of two to twenty-three months and is known as the pneumococcal conjugate vaccine (PCV). Other children may also get this vaccine at a later age if they have certain medical conditions. The pneumococcal polysaccharide vaccine (PPV) is recommended for adults sixty-five and older or who have other medical conditions. PPV is also given to children over the age of two with chronic illnesses.

With immunization, parents don't need to worry that there children will contract the illness or a bacterium that is resistant to many antibiotics. Yet, in this country many parents question the importance of vaccinations as doctors and parents a world away wish they had the opportunity to immunize.

Antibiotics, Dentists, and You

Earlier this year the American Heart Association changed its guidelines on which patients would require antibiotics prior to a dental procedure. Last revised in 1997, these recommendations were established to provide guidance on what antibiotics to use and which patients were at risk to developing an infection of the heart valve which is known as endocarditis.

Endocarditis, fortunately, is a rare but serious infection. It occurs when bacteria enter the blood stream and deposit on to a heart valve causing damage. Bacteria enter the bloodstream via intravenous drug use but also can occur, but uncommonly, through medical procedures as well as dental procedures. Once present, bacteria can then to spread to different parts of the body causing further organ damage. If severe enough, surgery is required to replace the diseased valve. Treatment is usually intravenous antibiotics for many weeks.

The current recommendations for endocarditis prevention will mean fewer individuals will need antibiotics.

Individuals recommended to still take antibiotics prior to dental work include those with:

• A prosthetic heart valve.
• A history of previous endocarditis.
  
• A history of congenital heart disease (check with your doctor on the specifics).
• Individuals who received a heart transplantation with heart valvular disease.

If you previously took antibiotics routinely prior to any dental work, there is a good chance you won’t need to any more. Check with your dentist and doctor. Research has shown that it often take years for newly announced guidelines or beneficial research results to become commonplace and practiced routinely. You might have an opportunity to gently educate them. The Council on Scientific Affairs of the American Dental Association also endorsed the new guidelines so your dentists should be aware as well.