I sat on my stool, sympathetically listening to her as she fought back a stream of tears. “Doctor, I have Shy Drager Syndrome, just like my uncle did.” Shy Drager syndrome. A rare, multisystem neurologic disorder, which in thirty years, I’ve never diagnosed. Before I was willing to accept her impressive diagnostic feat as correct and let my mind wander to the cruel injustice it would be to see this otherwise lovely woman sentenced to an unremitting fatal illness, I had one more question. “Your uncle had Shy Drager ?” Without flinching, she replied, “he must have, doctor. He had the same symptoms I have. He was tired all the time.” Fortunately for her, the fatigue was due to a more common and treatable malady, sleep apnea, a diagnosis made when her husband entered the exam room and sheepishly admitted, that contrary to her denial, his wife did in fact snore.
Since the advent of the internet, patients no longer present to physicians the way they have for centuries. In a time honored tradition, physicians learned to listen and take a medical history– interpreting a patient’s recollection of symptoms and a course of events that told the story of their illness. Much of the clinical training of physicians is dedicated to learning what historical clues are critical to making the correct diagnosis. Although the physical exam and laboratory tests may help confirm a diagnosis, the most fertile area for making the diagnosis remains the patient’s history.
As the doctor patient relationship has evolved, patients have played a more active role in deciding the course of diagnostic tests and treatments they will undergo, and doctors have become less paternalistic. The one area where I think the relationship has gone astray is in taking the history. I have always been critical of doctors using forms or assistants as a substitute for taking a history. I long for the days when patients presented symptoms and stories that I could easily recognize. Patients, especially those with persistent symptoms that frequently defy a satisfactory diagnosis –fatigue, dizziness, muscle cramps–resort to aiding in the process by diagnosing themselves with the many resources available on the internet. Without training and clinical intuition, these exercises rarely lead to a correct diagnosis, but frequently lead to diagnostic considerations that cause anxiety and fear in patients.
As I move on to the next patient, I can instantly tell what the diagnosis is. He sits on my stool, reading from his iPad a list of disease possibilities and diagnostic tests that must be run and then hands me copies of journal articles he has culled from an online source. Another case of “Recurrent Googleitis.”
Norm Solomon, M.D., has been the medical director at the MPTF Westside Health Center since 1995.