Reading between the lines

February 25, 2011

At varying stages in his medical career, the author has learned to acquire information in different ways.

At varying stages in my medical career I have learned to acquire information in different ways. As a beginning medical student, I concentrated on case studies. As I became a resident, my focus changed to taking histories and physical exams. Now as an attending physician, I have learned to use both body language and my own emotional reactions to enhance patient care.

A lot of information can be found in the subtleties of gestures and mannerisms.

When Mrs. W walked into my office, I knew that she was depressed. Her eyes were focused on the ground, and her gait was slow and deliberate. As I took her history I learned that she had been losing weight at an alarming rate. She was having abdominal pain and couldn't eat. Her examination showed a thin woman who was otherwise normal. I described the workup for her weight loss and prescribed an antidepressant.

The results of her lab tests were normal. There were no thyroid problems, diabetes, or anemia. She was up to date on cancer screening. The only abnormality was a CT scan of the abdomen that showed a small nodule on the liver. Although I had doubts about the importance of this finding, there was no other explanation for her weight loss and abdominal pain. So I ordered a biopsy and waited. In the meantime, her depression was starting to break, and she was feeling better. But her weight was still dropping. She was now below 100 pounds.

When the liver biopsy results were normal, she came to my office for a follow-up visit. I had no magical diagnosis to explain her condition after 3 months of searching. She still wasn't eating. She appeared frail, as if the slightest breeze would knock her over. I reviewed her symptoms again, and we discussed her home situation. There was nothing new to help guide treatment. Feeling uncomfortable with my own inability to make a diagnosis, I asked her to follow up in 2 weeks.

I found myself deep in thought one morning as my next patient walked in. He was a large man. For the first time I felt threatened in my exam room. I cautiously took a history and examined him. As he strode out to the reception area, he abruptly turned toward me. "By the way, thank you for caring for my wife," he said.

I quickly looked at the demographic page on my computer and realized that although they had different last names, this was Mrs. W's husband. I quickly called Mrs. W. I asked immediately, "So how long has he been abusing you?"

There was a long pause, and then she spoke softly, "Dr. G. I..." And then she hung up.