Patients Know Their Body Best

Last week, I saw a gentleman with a wide range of somatic symptoms that mysteriously appeared like clockwork every two weeks for years. Evaluation in the past failed to yield the diagnostic answer. He was convinced he had a fungal infection in his blood stream. Fortunately, I was able to reassure him that he had no evidence of a systemic fungal infection. I doubt he believed me.

When I encounter patients who are convinced that a certain ailment afflicts them, I pause. In my professional naivet̩, I used to assume that the patient did not have any idea what they were talking about. With time and experience, I have learned that, while patients may lack a formal medical knowledge, they are experts where I am not Рin the unique workings and mechanism of their own body. If we are able to combine my expert knowledge of medicine with their expert knowledge of themselves, we often are a better diagnostic duo than either of us would be on our own.

Admittedly, I can often reassure patients that whatever they fear is not a reality, and many of them already know it. The patient who has heartburn but is worried that it is a heart attack because their uncle just died from a heart attack. Dizziness from fluid in the ear prompting concern about a brain tumor because a popular celebrity just described how they were diagnosed with brain cancer after experiencing a similar symptom, and so on.

Others patients are convinced that an unrelated and vague constellation of symptoms are due to a single problem – thyroid disorder, heavy metal poisoning, or Lyme disease. These types of visits are hard to handle. While I may inwardly scoff at some of the ideas that seem straight from a cousin's Facebook post, I remind myself that beliefs are powerful and can affect health significantly. Consider the placebo effect which can render a powerful benefit simply because a patient believes.

I recently was reading about a validated clinical prediction rule for chest pain in the ambulatory setting. The instrument assesses five elements of the chest pain history and characteristics that can help predict whether the pain is cardiac or non-cardiac. Interestingly, one of the five elements is whether the patient believes the pain is heart-related. This is scientific evidence that what a patient believes can be an accurate and helpful tool in diagnosis.

Getting back to my patient concerned about his overwhelming fungal infection, I wonder about the best approach. Clearly empirical evidence that there is no underlying infection is not going to be good enough because it has been provided to him before. I repeated the testing because it is something I can do to reassure us both. Logic often fails to work because we do not start from the same place. I believe what science tells me about disease and health. Most patients believe what they read, hear, and think on an equal or even higher level than what science can prove. In the end, I rely on the therapeutic relationship which maintains my commitment to help and care even when I cannot give a definite answer or treatment.