Pathognomonic names the disease: swearing to the truth means admitting to a lie


You swear to no drugs, me o my.

If it’s the truth, can you tell me why

My belief you demand

As you raise your right hand

When you know perfectly well that you lie

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m back from a working vacation in Petersburg, Alaska, and an educational trip to San Diego.

Pathognomonic comes from the words pathos meaning disease and gnomon, meaning name; roughly speaking, it names the disease.  Koplik’s spots, for example, a particular sort of lesion on the gums, occur only in measles.  If I would see Keiser-Fleischer rings in the irises I would know instantly that the patient had Wilson’s disease.  A bull’s-eye rash happens only in Lyme disease.

When I was a med student an intern told me that palpable lymph nodes just above the elbow, on the inside of the arm were “almost” pathognomonic of infectious mononucleosis (they aren’t).

Imagine a patient fixing his or her eyes on yours, raising a right hand and saying emphatically, “Doctor, I swear to God…”  (It doesn’t matter what comes after that.)  Such a vocalization and gesture rate as pathognomonic for patient lying about drugs.

Bill Clinton used the same facial expression when he said, “I did not have sexual relations with that woman.”

Really, a person telling the truth doesn’t need to swear or use righteous indignation.

I let the patient finish prevaricating.  I nodded.  “I live in the real world,” I said.  “You’re sick.  You need to be in the hospital.  Just like I’m ordering a patch for your tobacco addiction and an ultrasound because your tummy hurts,  I’ll put you on the detox protocol.”

The righteous indignation had faded after I said I lived in the real world.  “For what?”

“For the drugs we found in your urine.”

The urine drug screen has never rated 100% for accuracy.  It has false positives and false negatives, and I know it.  I suspected drug use, and the patient admitted to marijuana.  But as soon as the patient fixed my gaze, and raised the right hand, I knew that I needed to start detoxification procedures for those amphetamines and opiates, and to test for hepatitis C and HIV.

I walked away from the interaction proud that I had dealt with the problems without backing the patient into a corner.  I had communicated my concern about the patient’s well-being, I didn’t try to be right, and I finished the admission with more energy than if I’d tried to get to the patient to admit wrongdoing.

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