Within the practice of medicine, there are what we call pearls, bits of knowledge that you don’t usually find in textbooks, or hear in lectures. It’s in the field where you understand them. Sometimes you know immediately that a phrase or idea is a pearl, but sometimes you don’t know that until later, sometimes much later. They’re easy to miss – especially when a doctor has been practicing for a while, lulled by repetition or fatigue or who-knows what. Only part of the doctor is in the examination room with a patient, the other part is wondering where to go for lunch, what team is playing what team, or which new fishing lures to buy for the next vacation. You know what I’m talking about.
During my third year of medical school, I did a clerkship in the primary care clinic at Mass General. One of my first patients was a young, married mom. She reported symptoms and showed signs of a urinary tract infection. There were traces of blood in her urine.
The diagnosis seemed straightforward. Then I noted bruising, both old and new, on the medial aspect of her left upper arm. She told me she had no idea what caused the ecchymoses. She seemed distracted and distraught, especially since her complaints were just urinary symptoms. What a find: an AHA! moment. Bruising, hematuria – she must have some kind of blood dyscrasia! A clotting disorder with incomplete penetrance? Idiopathic thrombocytopenic purpura? Idiopathic something or other?! I left the room to find my attending physician. At my level of training, med students had to run everything by a supervising physician, a real doctor, before we could let a patient leave the clinic. (A good policy.)
I told the attending about my patient’s history and physical findings. My differential diagnosis list was impressive. The list of laboratory tests to sort out the particular disease, with names that resembled organic chemistry compounds, was even more impressive. Their cost was enough to purchase a compact car (in those olden days).
The attending and I returned to the exam room. Within 90 seconds my patient was sobbing. He asked her about her urinary symptoms, then about the bruises. She told him the same thing that she’d told me. “We see that pattern,” he said, “when a hand grabs an arm, an abusive, violent hand.” My patient crumbled. Of course, the diagnosis was domestic violence. How did he do that – get to the heart of it, in seconds?
Later, my attending told me, “Faith, often patients come in for two reasons. They have a symptom, a good reason. It’s the admission ticket, the permission they give themselves to ask for help. They believe that they’re unworthy. It’s what’s behind their need to have a good reason; that’s the real reason. The real reason is more important.”
Some time later, I saw a teen on a Sunday afternoon, complaining of abdominal pain, a good reason. It looked like classic appendicitis. I remembered that pearl. Her real reason: she couldn’t bear one more day of bullying at school, tormented for her obesity.
That encounter at Mass General became a defining moment for me; the good reason – real reason principle makes practice so much more rewarding. It’s there that you really, really get to help. I’m still talking about, using and passing on that pearl, after more than 20 years. A cautionary reminder – the patients still need treatment for the good reasons.
A corollary: When you hear hoof beats look for horses, not zebras. Common things are common.
