Some time ago, a patient was sent to me for a scope test. This is hardly a newsworthy event since I do thousands of scope exams every year. This patient had a known, benign narrowing at the lower portion of the esophagus, which is called a ring. Years ago, another gastroenterologist stretched the ring which had been catching food on the way down.
My assigned task was to examine the ring and determine if a
stretching was necessary.
This introduction of this case is the set up for the point I
wish to make. Too often, medical
decisions are based on objective data without sufficient consideration of the
patient. Consider a few hypothetical examples.
An MRI of the back shows disc protrusions in the lumbar
spine. A surgeon reviews the study with
the patient and explains the rationale for surgery. However, a detailed review of the patient’s
symptoms suggests that the back pain may not be caused by disc protrusion at all. Indeed, many folks over certain age will have
‘disc disease’ without suffering any back pain.
An oncologist recommends intensifying treatment on an
elderly based upon the results of a repeat PET scan. The treatment is toxic and the patient feels
well and cherishes his active life. Has
the expected negative effect on the patient’s quality of life been sufficiently
considered?
A doctor advises laxatives as an abdominal x-ray showed stool in the large bowel. However, the patient was not constipated.
My point is that objective data should be viewed in the
context of the human patient and his story.
When this is done, there will be many examples when the objective data becomes
less relevant. As an example, when I
performed the scope exam of the patient’s esophagus which began this post, I
did identify the ring. However, prior to
the exam, he indicated that his swallowing was perfectly acceptable. So, based on his own account, no stretching
was necessary.
Listen to your
patient; he is telling you the diagnosis.
Sir William Osler
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