Wednesday, August 1, 2007

Knowing the question

To make a diagnosis a physician needs to know how to obtain the appropriate information. This information often comes from listening to the patient. Occasionally it is acquired in the process of examining the patient. Less often the answer lies in the tests that are ordered, blood work, x-rays and the like. Sometimes the most important information comes when the physician asks the patient questions. These questions maybe about symptoms the patient is experiencing but at times there is information that is more important than symptoms. Here is an illustration.

One of the most brilliant physicians I have ever worked with is Dr. Lane Gentry. At the time I was a medical student Dr. Gentry was practicing infectious disease. Later he became Chair of the Department Medicine and Chief of Staff at the primary teaching hospital affiliated with Well Known Medical School. For me Dr. Gentry was an outstanding role model. I learned more about practicing medicine in the 30 days that I spend on Dr. Gentry's service than in the previous three years of my training. Dr. Gentry was a master at knowing the right question to ask.

Each Friday in our city of three million, a city wide infectious disease conference was held. The conference was attended by physicians from all over the city and represented the most difficult infectious disease cases of the past week. The auditorium was always packed.

The ultimate stump the professor routine was the format. If the patient was well enough to attend he or she would be on stage where a resident physician would present the events leading up to the diagnosis. At this conference as well as working with patients in the County Hospital I got my first up close look at diseases as tuberculosis, bacterial meningitis, hepatitis, and HIV/AIDS, which then did not have a name since the cause had not yet been identified.

I will never forget the conference that began with a elderly, tall, thin, African American gentleman sitting on stage. He looked as if he would like to smile but was too intimidated by the fact that about a hundred and fifty men and women in white coats were staring at him. He was well dressed in coat and tie appearing as if he was on his way downtown to a desk job in one of the high rise office complexes.

The resident physician began by introducing the patient to us as Mr. DW (initials or chart numbers only were used). The patient was brought to the doctor by his family who thought he needed medical care. When ask directly the patient had no complaints. The family's complaint was the Mr. DW had begun to "look older." When ask to be more specific his daughter said that his ears were wrinkling and so was his forehead. This seemed to happen overnight. Over the next several weeks many tests had been done and the diagnosis was obtained.

Now it was up to the five infectious disease doctors seated on the front row who had never met the patient to come up with the diagnosis. Sometimes the questioning could go on for an hour as each took their turn. Dr. Gentry immediately raised his hand. "May I ask the patient a question?" Dr. Gentry ask the resident.

"Certainly," came the resident's reply.

"Sir, do you ever eat armadillos?" Dr. Gentry's asked.

Immediately Mr. DW replied, "Everyone I can catch!" his smile finally breaking through.

"Mr. DW has cutaneous leprosy," Dr. Gentry stated to the audience. "The test that made the diagnosis was a skin biopsy of his ear." Sure enough, the microscopic slide was then projected on the screen, revealing the bacteria found on the skin biopsy. Mr. DW had begun his treatment with the appropriate antibiotics and the wrinkled skin would begin to disappear.

Knowing the questions. The answer is easier to find once the right question is asked.
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