A glance at my dialysis patient's blood count reminds me the Recession – everything went down except the level of anxiety. It's the third month like this. I told my patient, "Well, we don't really know what's happening. Your white cell and platelet counts are both coming down, almost as quickly as you're going anaemic." I suggested him to have a bone marrow test to figure out the problem.
Of course, my patient didn't believe me. He was nervous about the bone marrow biopsy examination. "Yeah, I bet you must have come to this decision after several round of blood tests," he hesitated. "But I'd rather wait and see. I'm feeling well."
I shook my head, but I gave in. All I knew was that I couldn't be sure I would miss something treatable. After all, the patient has already a problem list long enough to bother about, including his diabetes, kidney failure, blocked blood flow to the legs.
My patient returned to my clinic last week. "C'mon, let's be brave," I asked him again. "Have you decided on the bone marrow study?"
"No, I guess not," my patient answered. "Not at the moment. I wish you don't mind. Can I say something? The problem seems to start ever since my leg problem three months ago. Right? The vascular surgeon saw me when my toes turned dark. And then I was told to take the medication cilostazol, which is supposed to open up my blocked blood vessels. I have a hunch that it's this drug that causes the plummeting blood counts that you kept mentioning to me over the last few months. I never have problem with my blood counts before taking cilostazol."
I paused, nodded, and was wordless. There was nothing to say. I looked at my patient for as long as I could without embarrassment, and then took a quick look at the desk reference of drug information. Bingo! The problem with blood counts after taking cilostazol has been well documented before. My patient has a point. Who in his right mind would want to go for a gruesome and painful bone marrow biopsy procedure if the problem might be solved by stopping a medication? I had never thought about it.
Well, we all know the moral of this story, don't we? William Osler taught us almost a century ago to listen to the patients because they are trying to tell us the diagnosis.
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4 comments:
That's inspiring, Dr Chow.
It is so true that medicine is always about thoughtful listening and careful thinking =] Thanks for sharing!
That's one insightful patient!
I once had a 89 year old anxious lady with uncontrolled hypertension and mild resp failure. She was then put on several antihypertensives after admission. During the stay, she repeatedly complained of backache and annoying muscle cramps and commented these symptoms were not present in the past. Of course, as a careless doctor like me ignored her somatic complaints. However, she insisted these were caused by the new medications, which included hyralazine.
Then I had a quick look in UPXXDate and it commented one of the not so common side effects for hyralazine was muscle cramps. Then I stopped it. 2 days later, muscle cramps resolved...
this was the first time I realised that even history from a 89 year old lady also counted.
Sunny, you're right. Clinician mindfulness has been a topic of considerable interest recently. Having a beginner's mind (opennesss) has been tauted as a tool to minimize "cognitive disposition to respond" (or cognitive biases if you prefer simple language).
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