August 3, 2011

In a previous article, “Your Doctor, The Master Chef” (, I compared the treatment process to the making of a gourmet recipe.  I teach by using analogies and “The Chef” is one of my favorites.

There are three basic parts to your visit to the doc.  Part one is the “listening” where facts are gathered and pertinent history is recorded.  Step two is the “touch” stage where you are examined.  The exam may include physical, chemical, electrical, and radiological probing of your physical being.  Step three is the “cooking” stage where your recipe for health is concocted and begun.

As a CSI (Crime Scene Investigator), most docs will combine steps one and two, collecting evidence from the minute they walk into the room.  Not long ago, patient “X” saw me for “anxiety”.  She was worried that something was wrong; she just couldn’t explain what she felt was wrong.  We talked for 15 minutes, followed by a brief review of her vital signs and a very cursory exam.  As I started into part three, formulating a treatment plan, Mrs. “X” quipped, “Aren’t you going to examine me.  You haven’t even listened to my lungs and heart!”

Mrs. “X” is not the first patient to complain about not having a stethoscope placed on their chests.  Most patients are oblivious to the techniques of an expert CSI tech.  I explained to Mrs. “X” that I had actually begun my exam before she had even gotten into the exam room.  To illustrate my point, let me digress.

I was walking out of my office as the nurse was weighing Mrs. “X” on the hall scale.  Mrs. “X”, a woman in her 30s, stepped easily on the scale and looked away as the nurse weighed her.  While she is relatively thin, she was uncomfortable with her weight.  I greeted her and she returned the greeting less than enthusiastically.  Mrs. “X” is usually gregarious and warm.  Again, she appeared uncomfortable.

On entering the exam room, Mrs. “X” appeared nervous, agitated, and somewhat aloof, all very unusual for Mrs. “X”.  I asked how her family was, she said “fine”.  She avoided eye contact.  Her complaints were vague and she seemed to be worried about a problem in her genitourinary track.  She had seen her gynecologist twice in the past two weeks and reported that both exams were “thorough and normal”.  She complained of being anxious but appeared nervous and somewhat defensive.  When I checked her pulse, her skin was moist.  She was sweating.  Her pulse was minimally elevated.  I checked her neck for an enlarged thyroid, finding a normal gland.

As I started to tell her what I wanted to do, she erupted in anger that I had not adequately examined her.  I had made the mistake of not putting my stethoscope on her chest.  I was going to order some labs, order a mild anti-anxiety medication, and set her up for a follow-up visit.    I didn’t need to do a more thorough exam today; my preliminary exam had revealed many clues and I was pretty sure I knew what was going on.  I’ve been a CSI tech for 28 years, I’ve seen this before.

Mrs. “X” pressed for an answer, again atypical behavior for this patient.  I asked her my favorite question, “What do you think is wrong? Is there anything else I should know?”  Mrs. “X” came back at me with the usual, “I’m not a doc, what’s wrong with me?  I’m not crazy!  Tell me what’s wrong!”

When pressed for an answer, I always go over the differential diagnosis ( in my head and then share it with my patient. 

  1. Anxiety Disorder - possible
  2. Thyroid Malfunction - unlikely
  3. Occult Infection - unlikely
  4. Guilt – very likely
  5. Other

Gently, I say “Mrs. ‘X’, I agree you are not crazy.  I don’t think this is anxiety or thyroid disease.  If I had to make a guess today, I’d guess you were having an affair.  Am I right?”  The last clue I needed to know I had correctly read the signs were the tears.  Mrs. “X” won’t feel better for a while.  Step three, the recipe for health is on the cooker.  Not bad for never having put a stethoscope on her chest!

Your Doc, like the CSI techs on TV, start collecting clues (examining you) the minute they greet you.  There are all kinds of exams, all kinds of test.  What’s important is discovering which villain is attacking you so a treatment plan can be made and balance restored. 

The next time you think, “But he didn’t even examine me”, think again!


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