The essentials of differential diagnosis should be ‘old hat’ to seasoned doctors, don’t you think? Say, a patient enters with belly pain that is off and on, but more on and more painful since she returned from a two month stay in a rat-infested orphanage in Africa. The patient hasn’t been to the doctor for a year, and is paying out of pocket on this particular day. The doctor’s assistant should, protocol dictates, weigh the patient, do a thorough intake history and take her vital signs. It is better if he does not tell you that the doctor running late for a meeting that is immediately after your visit. Nor should he joke about the doctor not wanting to have the patient’s mother in the exam room when he arrives.
When the doctor does enter he should greet the patient that is sitting on the exam table and not stare at the patient’s mother in a stupefied manner. The doctor should then extract more details from the patient about the illness, especially if the history obtained by the assistant is sparse. For example, in the case of belly pain the doctor (or someone!) should ask (at least): What kind of pain? Where? How long? What makes it better? Worse? Any diarrhea? Nausea? Vomiting? Constipation? Belching or other gas? Pain or burning with urination? In addition, someone who’s been traveling out of the country should be asked: Did you eat any fresh produce or native food? Drink anything that wasn’t bottled? Swim in any fresh water lakes or rivers? And then after the questions are answered the doctor should do an abdominal exam, preferably with the patient flat and knees flexed for a relaxed belly. The stethescope should be used to listen to the abdominal sounds. (Borborygmi is one of the sounds the gut makes and I had to include it because it’s a weird word and I like it.) The exam should be purposeful and include a light and deeper palpation, done with one and/or two hands. Percussion should also be performed.
Then the doctor should approach diagnosis mode and come to a conclusion about what to do for the patient. He should not shrug his shoulders and rub his face with both hands like the stress is overwhelming. He shouldn’t say he’ll treat for heartburn or giardia and then rescind that decision because there is no indigestion or diarrhea. He should not, at the same, time continue to look at the patient’s mother with a smirk, taunting her to “run the show” as he’s alluded to in the past. He should emerge with a plan and fill the role as the trusted leader in helping the patient to wellness.
By the end of the appointment I observed a couple of days ago, only about 20% of the abdominal pain protocol had been followed. There was no diagnosis, no closure, only a vague reference that maybe the patient should see a ‘female doctor’. “Oh, and maybe some blood work,” he said, as he left the exam room. To further convince the patient and her mother of his incompetence, the doctor reappeared momentarily in the doorway and asked “Can I interest you in a flu shot? Or a Guardasil vaccine?” And laughing, he was gone.