Internal Medicine Week 3: Avoid the Comfort of the Mundane
The first semester of PA school, I read a book called How Doctors Think
. I remember a story that told of a young physician trying to find the source of infection for a hospitalized patient. He mentioned how everything was done, but the source could not be found. The problem was that no one had thoroughly examined the patient’s buttocks. He had a pressure ulcer that was infected. When clinicians go the distance, more often than not, they will find what needs to be found. This anecdote was confirmed by three patients from the week.
The first was a gentleman in his late 50s who was perfectly healthy. He asked lots of questions as to why he had to come in every year for a physical and various testing, given the state of his health. It came time for the digital rectal exam to assess the health of the prostate. I found a 2 cm nodule, which surprised me, because I had never felt an abnormal prostate before. The patient was so grateful that we ask him to come in annually.
The second patient was a man in his early 70s who again was here for his comprehensive exam. He thankfully had come in a few days earlier to have his blood tests and urine checked. Unexpectedly, his urine was positive for trichomonas, of all things. Keeping that in mind, I went through a thorough sexual history, all of which came back negative. I was dumbfounded. I went through the examination and figured I might as well do a genital exam, just to cover all the bases. I will spare the details but I did find the source of an infection simply because of a thorough inspection. Again, the patient was speechless because of the extra effort.
The third patient was a young girl who had recently missed her period. She went to a “doc-in-the-box,” and they told her she was not pregnant and that her TSH was 54. They wanted to start her on levothyroxine, but she wanted to check with her regular doctor first. I heard the story and immediately doubted the results she had been given. So, I told her that this may have been an error, but bottom line, we needed to see for ourselves. We ran some tests and were blown away by the results. Her TSH was now 74, and her free T4 was 0.59. Through a series of other labs, we determined she had an autoimmune condition called Hashimoto’s thyroiditis. The patient was comforted by our drive to help her.
Routine, thoroughness, and the avoidance of relying upon others’ conclusions will help us to be better clinicians for our patients. The challenge is to avoid the comfort of the “mundane.” Each patient is different, and our repetitive H&Ps must be tailored to that individual. There will come a day when we have practiced medicine for 10 or 20 or 30 years. Will we rely upon a “seen-it-all” mentality, or go the extra mile for the sake of the patient?