Every Patient Tells a Story Read Online Free PDF Page A

Couldn’t be a cold shower; even a warm shower didn’t quite do it. But if she could stand under a stream of water that was as hot as she could tolerate, the vomiting would stop and the nausea would slowly recede. A couple of times she had come to the hospital only because she’d run out of hot water at home.
    Recently, a friend suggested that maybe this was a food allergy, so she gave up just about everything but ginger ale and saltines. And that seemed to work—for a while. But two days ago she’d woken up with that same bilious feeling. She’d been vomiting nonstop since yesterday.
    Maria Rogers was a small woman, a little overweight with a mass of long brown hair now pinned back in a barrette. Her olive skin was clear though pale. Her eyes were puffy from crying and fatigue. She looked sick, and was clearly distressed, Hsia thought, but not chronically ill.
    How often did she get these bouts of nausea? she asked the girl. Maybe once a month, she told her. Are they linked to your periods? Hsia offered hopefully. The girl grimaced and shook her head. Are they more common just after you eat? Or when you’re hungry? Or tired? Or stressed? No, no, no, and no. She had no other medical problems, took no medicines. She was a social smoker—a pack of cigarettes might last a week, sometimes more. She drank—mostly beer, mostly on the weekends when she went out with her friends.
    Her mother had been an alcoholic and died several years earlier. After leaving college she had been living with her father and sister but a few months ago moved into a nearby apartment with some friends. She had no pets, had not traveled within the past year. Had never been exposed to any toxins as far as she knew. Hsia examined her quickly. The gurgling noises of the abdominal exam were quieter than normal and her belly was mildly tender, but both findings could simply be due to the vomiting. There was no sign of an inflamed gallbladder. No evidence of an enlarged liver or spleen. The rest of the exam was completely unremarkable. “As I walked out that door,” Hsia explained to me, “I knew I was missing something but I had no idea what it was. Or even what to look for.”
    More Than Just the Facts
    Dr. Hsia was a resident in Yale’s Primary Care Internal Medicine residency training program, where I now teach. She told me about Maria Rogers because she knew I collected interesting cases and sometimes wrote aboutthem in my column in the New York Times Magazine . In thinking about this case, Amy told me she knew from the start that if she was going to figure out what was causing this patient to suffer so, it wasn’t going to be because she had greater knowledge—because Maria Rogers had already seen lots of experts. No, if she was going to figure it out, it would be because she’d find a clue that others had overlooked.
    The patient’s story is often the best place to find that clue. It is our oldest diagnostic tool. And, as it turns out, it is one of the most reliable as well. Indeed, the great majority of medical diagnoses—anywhere from 70 to 90 percent—are made on the basis of the patient’s story alone.
    Although this is well established, far too often neither the doctor nor the patient seems to appreciate the importance of what the patient has to say in the making of a diagnosis. And yet this is crucial information. None of our high-tech tests has such a high batting average. Neither does the physical exam. Nor is there any other way to obtain this information. Talking to the patient more often than not provides the essential clues to making a diagnosis. Moreover, what we learn from this simple interview frequently plays an important role in the patient’s health even after the diagnosis is made.
    When you go to see a doctor, any doctor, there is a very good chance that she will ask you what brought you in that day. And most patients are prepared to answer that—they have a story to tell, one that they have already told to friends