As a medical student I was in awe when a professor looked at a patient’s hands or nail beds and described their medical condition without taking a history. I was also enthralled by a TED talk by the best selling author, Abraham Verghese, where he described a lesson that Arthur Conan Doyle, author of Sherlock Holmes, learned as a medical student at the medical school in Edinburgh, Scotland from the famous physician Dr. Joseph Bell.
Arthur Conan Doyle described the following exchange between Dr. Bell and his students. A woman comes in with a child, and the woman says, “Good morning.”
Bell says, “What sort of crossing did you have on the ferry from Burntisland?”
She says, “It was good.”
And he says, “What did you do with the other child?”
She says, “I left him with my sister at Leith.”
And he says, “And did you take the shortcut down Inverleith Row to get here to the infirmary?”
She says, “I did.”
And he says, “Would you still be working at the linoleum factory?”
And she says, “I am.”
And Bell then goes on to explain to the students. He says, “You see, when she said, ‘Good morning,’ I picked up her Fife accent. And the nearest ferry crossing from Fife is from Burntisland. And so she must have taken the ferry over. You notice that the coat she’s carrying is too small for the child who is with her, and therefore, she started out the journey with two children, but dropped one off along the way. You notice the clay on the soles of her feet. Such red clay is not found within a hundred miles of Edinburgh, except in the botanical gardens. And therefore, she took a short cut down Inverleith Row to arrive here. And finally, she has a dermatitis on the fingers of her right hand, a dermatitis that is unique to the linoleum factory workers in Burntisland.” All of this information was obtained within seconds of the patient being in front of the famous Dr. Bell.
I have prided myself in being able to estimate a patient’s weight and geographic origin of birth by a patient’s accent. I try to estimate a patient’s age. But I have found that if I overestimate a patient’s age by more than ten years, it is likely that the patient has one or more chronic conditions. For example, a patient looking older than the stated age often has a higher BMI, might be a smoker or consume multiple alcoholic drinks every day, does not exercise regularly, may have COPD, may have a type A personality, may suffer from excessive anxiety or even depression, may have diabetes\metabolic syndrome, possibly hypertensive, may have diabetes mellitus, may have joint pain\arthritis and the list goes on.
On the other hand if the age estimate is 10 years younger than the actual age, the patient is likely to have a BMI <25, be normotensive, have a normal pO2, exercises a few times a week, a non smoke or drinks alcohol in moderation, normal cardiac and pulmonary reserve, not on multiple medications, and likely to be receiving regular preventive medical care.
What does this have to do with our practice of clinical medicine? The patient younger than their stated age is probably going to be a compliant patient and will look for non-medical solutions for minor healthcare problems. If the patient is going to be scheduled for a surgical procedure, it is likely the patient’s health will allow him\her to safely undergo the procedure.
Now for my observation on the patient appearing older than the stated age. He will be looking for a pill or procedure as a solution to their medical compliant. This patient may be less compliant than the younger looking patient. If this patient is considering elective surgery he will likely need more preoperative medical attention from his PCP, cardiologists and other specialists. These patients may have more difficulty in the post-operative period and require more rehab if they are considering orthopedic or cardiac surgery.
I have not put this observation to an evidence-based test but I have found this simple estimating technique may be helpful in my assessment of the patient and my discussion with the patient about treatments including surgery.
Neil Baum is a urologist at Touro Infirmary, New Orleans, LA, and author of Marketing Your Clinical Practices: Ethically, Effectively, Economically. He can be reached at his self-titled site, Neil Baum, MD, or on Facebook and Twitter.