“Dr. Liu, I don’t think he has diverticulitis.”
So said the second-year medical student. She had just completed her first year of anatomy, biochemistry, pathology, and introduction to doctoring at the local medical school. One of the sharpest medical students I’ve proctored.
Like many summers, I’ve been fortunate to spend time with the next generation of doctors. These future doctors were brimmed with enthusiasm and energy. Instead of taking time off to relax before second year, eyes bright and eager to learn they decided to devote more time with patients. I remember putting on a similar short white coat, stuffing my pockets with a stethoscope, reflex hammer, pens and notepad, and hoping to somehow look the role even if I still didn’t feel quite up to the role.
As a practicing primary care doctor and local community preceptor, I don’t always feels quite up to the role as an example of a great doctor. Nevertheless, I feel compelled to share what I know. So with every medical student I’ve taught, I’ve simply said the following:
Your professors and attendings are far more skilled and educated than me. So the only thing I will ask you to remember is that taking an accurate history and performing an excellent physical exam still matter in the 21st century, even with all of the fancy high-tech machinery, lab tests, and treatments we have. Unless you truly know the patient’s story, you won’t be able to help her. Better care is mindfully listening to your patient!
To reinforce this, with every medical student I always review the article by Dr. Jerome Groopman and Dr. Pamela Hartzband: “Anchoring Errors Ensue When Diagnoses Get Lost in Translation,” case number 2. In this case, an elderly man complained of fatigue and no stamina when golfing. He was evaluated by his internist, cardiologist, pulmonologist, and ultimately an endocrinologist. The endocrinologist asked one important question: “What do you mean by fatigue and lose stamina?” After all of the referrals and work-ups which demonstrated normal heart and lung function, it was this question and noting a couple things on physical exam that correctly diagnosed the patient. He had a circulation problem. Once fixed surgically, the patient resumed his golfing.
How much time, energy, and cost would have been saved by everyone involved if getting an accurate history and performing an excellent physical exam happened the first time? Also less stress for the patient. No need to have additional appointments or tests. Better care. Less cost.
So, this second-year medical student presented the following. A 50-year-old man, who is in otherwise good health, presented with sudden onset of left lower abdominal pain. He felt nauseated. The pain was so unbearable that he went to an urgent care. He was told that he had diverticulitis, an infection of the lower colon that is common in middle age/older adults, given antibiotics, told to drink plenty of fluids, and follow-up with us the next day. He is much better.
So what’s the problem?
He felt much better within two to three hours of taking the antibiotic! His abdominal pain symptoms were not constant. When I asked him more about his pain, he said that the abdominal pain increased and decreased in intensity. Also it started in the middle of the back before going down to the lower abdominal area. It seemed like it traveled.
She handed me some papers the urgent care doctor had given the patient.
“Does diverticulitis cause blood in the urine?” she asked.
The other doctor didn’t comment on that lab result. Yet there is was. A few red blood cells in the urine. Naked to the eye, but detected by the lab analyzer.
So we went back and interviewed the patient together. The pain was so intense that he felt nauseated. He could not find a comfortable position. Drinking plenty of fluids seemed to help. We examined his abdomen. No sign of tenderness anywhere. If he hadn’t told us his story, this could have been a routine physical exam.
Mr. Smith, we’re glad you’re feeling better. Turns out we think you have a kidney stone and not diverticulitis. Diverticulitis pain typically is constant and typically does not respond to antibiotics as rapidly as you noted. So, we would recommend you stop your antibiotics and continue increasing your fluids to flush the kidney stone out. We will order a CT scan to confirm it.
If we had simply concluded that since Mr. Smith was doing better, we should continue with treatment and finish his antibiotics we would have been making a mistake. If we had advised him that if his symptoms should come back, it would be due to his diverticulitis and that he would need antibiotics then we would have been an error. It would have been a misdiagnosis, a diagnostic error.
If we are to make care more affordable and better, we need to continue to provide adequate time for doctors and patients converse. We need to focus on diagnostic errors, something that patient safety expert and UCSF professor Dr. Bob Wachter has discussed. We need to ensure our health care system has a robust primary care workforce that is well trained on the history and physical exam as touted by Stanford professor Dr. Abraham Verghese and the Stanford 25 blog.
Our patient’s CT scan revealed a kidney stone that was small enough for him to pass. The stone descending through the ureter was the reason for blood in the urine. He now knows to drink plenty of water to decrease recurrence.
Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.