LET’S take a look at two possible scenarios in a doctor’s consultation room. One reflects how a medical consultation should be carried out. The other is a no-no.
Scene 1: “Doctor, why you ask so many questions? Why you ask about my sex life? The other doctor very good - he just put his stethoscope on my chest and say I got bronchitis.”
Scene 2: “My doctor very good. He spend so much time asking me about my sickness and explaining why I cough for so long.”
Question: Who do you think is the smarter patient? And the better doctor?
How do doctors make a diagnosis
There is no magic about this. All who practice medicine, from medical students to consultants, follow these golden rules:
1. Take a good history from the patient
2. Perform a competent physical examination
3. Carry out investigations if necessary
There are no shortcuts!
A 50-year-old patient dropped in to see a physician. She looked extremely distressed. Her face was swollen, her lips were raw in parts and encrusted with painful scabs. Her skin was covered with blotchy red swellings.
“Doctor, last week I had a sore throat and I went to see Doctor Y. He gave me this antibiotic (erythromycin written on a slip of paper) and the next day I got this rash. I went back to see him and he said I was allergic to this antibiotic. He treated me with injections but I am still sick. I have ulcers in my mouth and throat, and I cannot eat for five days.
“I went back to him three times but I cannot get well. So my friend asked me to see you.”
The physician painstakingly asked her to describe her original symptoms in detail, then delved into her past history. Fortunately she was too desperate to say, “Why you ask so many questions, lah?”
“I have high blood pressure for many years and I am taking this drug (shows the doctor a pill labelled as hydrochlorothiazide – a diuretic). Three weeks ago I went to see another Doctor X and he pricked my finger to check my blood and he said that my uric acid was very high (shows test result with slightly elevated uric acid level) and if I am not treated I will get gout. He put me on this medicine (tablets recognised as allopurinol) and I have been taking one pill every day since.”
“This is the cause of your allergy, not the erythromycin! Allopurinol is a common cause of severe reactions and what you have is called the ‘Stevens-Johnson Syndrome’ named after the two doctors who first described it. The allergy affects not only your skin but also your mucous membranes, that is, the soft wet lining of your mouth and lips, your private parts and sometimes even your eyes and internal organs. You can go blind or even die from this syndrome. I am sure your private parts are affected.”
Blushing, “Yes, doctor.”
“Anyway, let me examine you now ? I also need to do some blood tests to make sure your other organs are not affected.
“The treatment for Stevens-Johnson Syndrome is high dose steroids but the most important thing is to stop the allopurinol. Let me give you a card saying that you have this severe allergy to allopurinol so it will not be prescribed to you accidentally again.
“I can assure you that you will recover fully. See me tomorrow and I will review you and go through the blood results with you as well.”
Lessons to be learnt
1. There is no substitute for a good, competent history. Many experienced doctors will say that, often, the diagnosis can be made from a good history alone. The examination will only confirm their diagnosis. Taking a good history requires more skill than a physical examination, and of course, more time. An experienced doctor can get to the root of the problem with a few key questions, while a young doctor may labour in circles. Listen to two doctors taking a history and you will be able to separate the men from the boys, so to speak!
2. Hydrochlorothiazide is a common and useful antihypertensive agent. However, all drugs have their unique side effects, and one of the metabolic effects of this drug is that it can raise the uric acid. In most cases, it doesn’t matter, but in patients who already have a raised uric acid, this may precipitate gout.
3. Hyperuricemia, or a raised uric acid level, in the absence of attacks of gout, is not an absolute indication for drug treatment.
The reason is that allopurinol is well-known for commonly causing severe reactions, and it should only be used when necessary. The cure must not be worse than the disease!
Similarly, many patients blindly take antibiotics for a viral infection (if antibiotics can kill viruses then we can cure AIDS easily and cheaply!) and expose themselves to needless risk of allergy, and occasionally this allergy may be life-threatening.
4. Doctor hopping is a dangerous pastime. If the patient had gone back to Doctor Y, he would have realised that allopurinol was the cause of the allergy. Doctor X was at fault for not asking about her past medical and drug history. However, every patient is entitled to a second medical opinion. It is the patient’s right, and it is the primary doctor’s duty to prepare a letter of referral for the patient, at no charge since it is from one doctor to another.
Patient A: “That doctor very itchy, lah. He asked me to take off my clothes, and even examined my breasts! The other doctor very good, he just put his stethoscope on my chest over my clothes and say I have bronchitis. I think he is using expensive stethoscope.”
Patient B: “I went to three doctors and they say I just have a flu. This doctor examined my chest and say I have water in my left lung and it is most likely due to TB. I think the others just pretend to examine me, lah.”
Question: Who is the smarter patient? Who is the better doctor?
Thought for the day: As a patient, are you willing to pay higher consultation charges for a doctor who spends more time with you?
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