Taking the pulse to get through the denial

How do we know what we know,

In a patient denying it’s so?

A two-week-old start

For a pain from the heart

Was part of a tale of woe.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

A doctor has to listen as carefully to what the patient says as to what the patient doesn’t say.  I don’t think any of the standardized tests given to doctors measure the ability of a physician to detect deception and denial in the history given, nor how to sneak through the web of drama and irony to get through to the truth.

I nodded while I listened to a patient talking about symptoms identical to the last three visits.  Taking full responsibility for the ruination of a perfectly good set of lungs, the patient seemed to me a little too cheerful.  In the middle of a digression I reached out my hand to the patient’s, and feeling the pulse, waited till the smile faded a little and I could speak without interrupting. 

“I think you had crushing chest pain for hours, going up into both sides of your jaw, with sweating and nausea and shortness of breath even worse than usual, about two weeks ago, and it went away and ever since then you’ve felt just terrible.”

The gaze dropped and the sigh came through over the gentle hiss of the oxygen as the smile faded. “That’s about the size of it.”  I kept my index and middle fingers on the pulse and I waited.  “You don’t think it was a heart attack, do you?”

“I do,” I said. 

“Well, I guess I thought so to, or else I wouldn’t have made the appointment.  I just didn’t want my daughter to know, she’d have made me go to the hospital.”  We looked at each other and burst into laughter.  “That sounded pretty stupid,” the patient said.

“There’s a difference between fear of hospitals and stupidity,” I said.  “We need an electrocardiogram and a chest x-ray.”

After the lab studies confirmed what I already knew, I started into the part of the interview known as the Review of Systems.  “Any depression?” I asked.

A shake of the head, followed by, “No, no, not at all.  Not anything worse than usual.”  I reached my hand out again and the patient’s forced smile fled.  “Yeah, I guess I’ve been pretty depressed ever since.”  I nodded and we laughed again and then we laughed because we were laughing about depression.

The patient gave me permission to write a good deal more information than I have, about a visit stretching over an hour and a half, and touching on issues of intergenerational conflict, ripples of familial dysfunction getting worse and getting better in children and grandchildren and great-grandchildren, nosology, intellectual honesty, freedom of choice, and game theory. 

I ended up giving bad news and reassuring at the same time.  I arranged for proper follow-up and explained new medications. 

Of course when that patient left I went on to the next one and apologized for running late.


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