The practice of medicine is mostly fairly routine and the medical decision-making process is usually straightforward. But not always. On any given day, there are usually a few patients that present with truly challenging problems—and those are usually the times when the stakes are highest to get it right.
At those key encounters, it’s surprising how often the presenting symptoms and the physical exam fail to reveal the proper diagnosis and course of action. How physicians manage these cases involves a lot more intuition and less hard science than you’d imagine. It’s probably a left brain/right brain phenomenon, with the computer-like left always processing the hard data but sometimes coming up short on information, and the intuitive right offering a more emotionally driven perspective.
I often sense an internal alarm when I’m seeing one of these patients. It can be a very subtle or, sometimes, a very strong sensation. Either way, it’s very reliable. It doesn’t tell me what’s wrong, of course; rather, it’s chirping, “Pay attention here. There’s something important going on.” (Occasionally, the alarm isn’t that polite and will be saying something like, “Wake up stupid! You might be making a mistake here. Don’t screw this up!”)
I started becoming aware of this mysterious phenomenon way back in my internship, when I was being mentored by a very wise and exceptional pediatric resident. This subliminal perception, he taught me, is quite often more valuable than the actual medical workup: Welcome it; listen to it. He taught me that, when evaluating an ill child and you feel this “sick sense,” it should demand being exceptionally attentive, even if test results are all normal. This sense should be a significant part of the decision-making process.
Before taking a history from the family or examining a sick baby, he would insist that I pay attention to my gut feeling upon entering the room as to whether or not the baby was really sick. Amazingly, I found that perception very reliable and the truly sick kids were almost always identified correctly. It’s not just me, of course. I’m quite certain that most doctors today rely on their instincts in much the same way.
Here’s a recent example of an elderly patient I saw in the office where my internal alarm really made a difference:
“Mrs. M” had been worked into my schedule during the lunch hour for an “upset stomach.” Upon entering the exam room, I noticed she didn’t look quite right, but I just couldn’t put my finger on it. As she was explaining what sounded like a very minor issue, that feeling came over me. Somewhere deep inside me, the bells started going off. “What’s going on?,” I kept thinking. “Nothing is adding up.”
“…and the smell of that dead rat under my house is all it is—it’s just making me a little queasy,” she was saying. Mrs. M is a very healthy 78-year-old and the sweetest woman in the world. She’s never one to come into the office with a minor complaint. She’d explained about the demised rat family under her house in considerable detail. As the story unfolded and she continued to downplay her symptoms I found myself wondering why she came in today at all. “This is unusual,” I thought as the bells kept dinging.
“…and I just hate to interrupt your lunch hour with this silliness. You work too hard and you need to eat,” Mrs. M mothered me as she downplayed.
Ding, ding, ding
Her physical exam was almost completely normal: vital signs and heart exam were normal. I heard minimal rales at the bases (crackles that can indicate fluid in the lower lungs), which is no big deal. Her abdomen was also completely normal—no tenderness, no swelling or masses. Nothing. Extremities? Normal again; no swelling.
Now what? My left brain was thinking, “There’s not much going on here, she’s probably okay. Just send her home on a medication for the nausea and see how she does.”
But…ding, ding, ding, ding, ding! My right brain was apparently offering a “second opinion.” I ordered an EKG.
Kaboom! The tracing was absolutely shocking. It was a classic textbook wave-pattern of dramatically elevated ST segments in the “inferior leads,” findings that any second year medical student would recognize. Mrs. M was in the middle of a major heart attack!
Three hours later, after a successful emergency angioplasty, Mrs. M’s heart was stable and she was resting comfortably. Back at the office, I felt like I’d dodged a bullet. I’d come perilously close to sending the sweetest lady in the world home in the middle of a massive heart attack.
I remember sitting at my desk that evening letting the two sides of my brain mediate yet another dispute: “Let’s dig in and get our charting done. There’s work to do,” said the stodgy left.
“Go home and enjoy a glass of wine. We deserve it,” the right countered.
Talk about a no-brainer.
Dr. James DeVore has been a full-time family physician in Santa Rosa since 1980. He’s medical director of St. Joseph Health’s Annadel Medical Group.
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