Four o’clock on a Friday afternoon is an anxiety-inducing time to be running behind in clinic as patients and staff both begin to show signs of wanting to leave. After finishing with a particularly complicated case involving chronic pain with multiple spinal and abdominal surgeries, I rushed into the room of the patient scheduled for 3 p.m. frazzled. The patient was an elderly man, seated with arms folded, looking sternly down a knobby nose at me. I couldn’t help feeling guilty as he stared at me as if I’d done something to unforgivably wrong him. Trying to appear less disconcerted than I was, I started taking a history for his complaint of back pain. He was extremely defensive to my every question, giving curt answers or throwing questions back at me. I got the impression that he loathed having to share personal information with me. I noticed throughout the course of history and physical examination that not only was his nose knobby, covered with two large bulbar outgrowths; his entire body was spattered with growths of varying sizes. They were skin-colored, apparently not painful and firm. I frowned as I took stock of a particularly large one on his forehead, about 2-inches across, trying hard to ignore the patient’s steady glare.
“Neurofibromas?” I thought to myself, but I wasn’t sure. Perhaps they were just warts (viral?), or some other infection or unusual presentation (dermatitis herpetiformis?) that was unfamiliar to me. When I delved into past medical history, the patient did not volunteer a cause for these growths. His attitude was so off-putting, I was afraid to ask specifically. “Are you sure there’s no other long-term medical condition that you have?” I inquired multiple times, phrased three distinct ways. He angrily negated each time. He also denied having HIV, syphilis or any immunocompromising disease. Finally, I decided that his chronic back pain was probably unrelated to whatever was causing the skin growths. I finished the remainder of my history and physical exam, scrolled through sagittal cuts of the patient’s MRI spine (which reported some stenosis of the spinal canal and nerve roots), and exited to present the case to the attending, convinced of a diagnosis of lumbar spinal stenosis.
When I returned, the patient remained sullen as my attending cheerily introduced himself. Seemingly ignoring the patient’s hostility, and without any hesitation, he began by gesturing at the growths on the patient’s face, “These spots — why do you have them?” There was a pause as the patient continued to glare at us. Then abruptly, he seemed to change his mind. “I have von Recklinghausen’s.”
“Ah, neurofibromatosis!” My attending continued with his jovial tone and turned to me excitedly. “That changes things for us, doesn’t it? NF type 1 means scoliosis is in the picture.” He proceeded to ask the patient to bend forward, revealing a curvature of the spine to the right. I groaned internally. That could well be contributing his chronic back pain and spinal canal stenosis. With the many neurofibromas on his back, I hadn’t been able to palpate straight down the length of his lumbar spine, but I didn’t think too much of it because there was no point tenderness or reproducible pain. And the sagittal cuts of his MRI would not have emphasized his scoliosis along the coronal plane.That piece of history was indeed a game-changer, and I was frustrated for not collecting it.
Shockingly, the patient was disarmed after being asked about something that I assumed he wanted to hide. It was as if he had been waiting all along for this question. With the dreaded “elephantitis” in the room acknowledged, he gradually discarded his glare and stiff answers, and by the end of the visit, even joked with us about his neurofibromas being a unique advantage every Halloween.
After we finished for the day, my attending brushed away my apologies for missing this piece of information. “Believe me, I understand,” he said kindly. But a month later, it still stands out to me, and I don’t think I will forget it for a long time. By not asking an obvious question, I allowed both the patient and myself to remain uncomfortable for almost the entire clinic visit. He was waiting for me to ask about the condition that had isolated him his entire life — I can understand why he was on edge.
But more importantly, it was a significant piece of information for diagnosing an etiology for his illness, and that is what really bothers me to this day. Just because of some momentary discomfort, I was willing to gloss over the matter. I guess we are never completely confident that we get a full history, especially when there is a lack of records. But as medical students, we should never knowingly settle for an incomplete picture.
Sometimes I find it hard to keep the point of medicine in sight — our goal is not to make patients happy, it is to keep them healthy. Often, these two overlap — but when they do not, we side with health. Patients may be reticent, sulky, angry, cranky or intimidating. For their sake, we cannot cut corners to make them (or us) more comfortable. As trainees, we have the luxury of asking endless questions, including the awkward ones, the unpleasant ones, and especially, the obvious ones.
Weijie Violet Lin is a medical student.
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