It’s Nothing

 

“I spent time and money to go to the doctor, and she said my cough was nothing – just a virus!” the man ahead of me in line at the coffee shop bemoaned to his wife, “What a waste.”

I bit my tongue as I debated light or dark roast.

I have heard this sentiment so many times – patients’ frustrations that instead of something serious or terrible, their symptoms turned out to be JUST a tension headache, a plain old cold, some dry skin, a mild sprain.

I get it. While feeling miserable, you scheduled an appointment, found a parking spot, waited, read stale gossip magazines, got undressed, waited some more, had ten minutes with a doctor, got redressed and sent off a $50 copay to your insurance company.

So when you learn your illness needs no treatment beyond TLC and Tylenol, it can feel as if the visit was a “waste”. You want something for your effort. You want to feel you got something for your time and money.     

But you did get something out of it – an expert evaluation – and hopefully some peace of mind. Your doctor thought about all the awful things you did not have. But all you heard was “it’s just a cold.”

Perhaps this is because we doctors don’t always do the best job of explaining what we actually do and how we think.

We are trained to think in a particular way – by building something called a differential diagnosis. We take your story, the symptoms you do and don’t have, the concerning or reassuring observations from your physical exam, the normal and abnormal findings of tests and create a unique picture of you, then consider which diagnoses do and do not fit.

Learning this way of thinking starts in the first few years of medical school with hours in the library and the lab. We then apply and grow this knowledge base in the hospital and clinic, where we are mentored by senior physicians, gradually taking on more responsibility and independence.

But medical school forms only a basic foundation. The house of medical practice only becomes a real home – with insulation, paint, landscaping, furniture – by caring for patient after patient after patient. By the time we’ve completed years of 80-hour weeks during residency, we’ve listened to and examined thousands of patients – seeing their quirks, their patterns of illness, their responses to treatment.

This continues as we practice independently as attending physicians. Like most homeowners, we tinker, mend, and redecorate our house for our entire careers, adjusting our practice based on new discoveries, research and experiences with patients.

So when you sit in a gown on the examining table, you aren’t the only patient in the room. The thousands of patients your doctor cared for before you are there as well – in her mind. Add in the thousands of patients seen by the the hundreds of doctors who trained your doctor, and it’s quite the party of patients.

So when you come to your doctor with even a seemingly simple complaint – let’s say, a stubborn cough that’s lasted for a month – she goes through a thorough thought process. She thinks:

Is the cough dry, wet, bloody, violent, worse at night, only at home, only at work? Does everyone in your family have the same cough? Do you have other symptoms like a congested nose, sore throat, vocal change, belly pain, headaches, heart palpitations, dizziness, joint pain, a change in weight, night sweats? Do you have a history of other illnesses like asthma or HIV or cystic fibrosis or cancer? Do you take immunosuppressant drugs or an ACE inhibitor? Are you a smoker? Are you up to date on vaccines? Have you traveled anywhere recently? Have you been in homeless shelters or prisons lately? Are you a coal miner, cave explorer, construction worker? Do you have a pet parrot? Do you raise chickens or sheep?

With each answer, her brain travels down a branching pathway – rerouting, eliminating possibilities, asking clarifying questions.

She also recalls the current data on area whooping cough rates, a recent local Legionella outbreak, and the latest graph of trends in the circulating respiratory viruses.

She remembers her prior patients with cough – the man turning blue and violently vomiting with pertussis, the noisy squeaking breaths of the woman with a tumor pressing on her throat, the cool hand and labored breathing of the man with severe pneumonia, the swollen legs and clipped sentences of the woman with heart failure. Do you seem like one of these patients?

She examines you – looking for overt and more subtle signs – the crackling sounds of fluid in the lungs, the whistles of wheezing, the rubbery feel of swollen lymph nodes by your collarbone, the gentle whoosh of a heart murmur, the puffed swelling of your feet.

She takes all of this information and weaves it into an assessment tailored exactly to you at that time. With that moment’s tapestry, she works to figure out what you have and how to best help you.

Sometimes your symptoms and exam are classic – we joke that your body “read the medical textbook” – and the next steps in treatment are obvious – an antibiotic, an ointment, an inhaler, a splint, physical therapy, counseling, changes to your diet.

Maybe you need supportive care –  time at home under a cozy comforter, your humidifier humming nearby, chicken soup on your bedside table – ways to help your immune system fight an infection for which we do not yet have a cure.

Other times we can determine what you do not have, but what is afflicting you is still unclear. This is when the further tests, a trial of a treatment, a consultation with a specialist or the tincture of time and reassessment at a future visit may uncover your diagnosis.

This process relies on work and from both the doctor and the patient. As doctors, we need to ask the right questions (and listen to your answers), examine the right areas, order the right tests. As patients, we can be open, honest and put some faith in our doctors.

And we can both remember that we are all still human –  we get tired, hungry, grumpy, distracted, interrupted. Sometimes we make mistakes. Sometimes the bureaucracy of the healthcare system gets in our way.

We can both be more vocal and transparent.

As a patient myself, I’ve found it helps to ask my doctor how she arrived at a diagnosis, what the risks and benefits of a test are, how certain she is that a course of treatment will help. I’ve done my own research on my condition, I ask her opinion of it. If I feel uncomfortable with a doctor – she doesn’t listen, doesn’t explain, doesn’t follow-up when needed – I seek care elsewhere.

As a doctor, I try to remember how confused and anxious I’ve felt as a patient – how imbalanced the balance of knowledge and power can feel between me in a flimsy gown and my doctor in her white coat.

So I aim to reassure my patients by being explicit about my thought process. For instance, when you bring your coughing child to me, I’ll tell you his lungs sound clear, his breathing isn’t labored and his oxygen levels are normal, making pneumonia or asthma unlikely. I’ll explain how his thick nasal congestion, the cobblestone-like pattern I see in the back of his throat and the worsening of his symptoms in the summer afternoon make post-nasal drip and environmental allergies the source of his cough.

The times when I’ve been too rushed or distracted to do this, instead saying “it’s just seasonal allergies,” I have found parents often stare back at me with a skeptical look – clearly dissatisfied and unconvinced.

Lifting the curtain and giving patients and their families a clear window into the medical thought process builds trust. It lets people know what they’re getting – a personalized expert consultation.

Your health is important. You deserve care from the hands and mind of someone who has dedicated years to diagnosing and treating thousands of people.

An online symptom checker, a Google search or the opinion of your cousin who’s a nurse will never substitute for an evaluation by a physician. You can DIY a lot these days, but some things should be left to the experts – plumbing, electrical work, and I would argue, your medical problems.

Find a doctor with strong credentials and a commitment to lifelong learning, who is curious, humble and treats you as a partner in your health. Then care for the things you’re able to (like exercise, sleep, diet), then question your doctor thoughtfully and kindly, while trusting in her training.

So when your doctor says your cough is just a cold, try to breathe a sigh of relief through your congested nose. Be glad you didn’t have lung cancer, tuberculosis, heart failure or any of the other maladies that swirled through your doctors head.

Go home, make some tea with lemon and honey and get under the covers. And if something changes – you get much worse, a new symptom pops up, something just feels wrong – go back to your doctor to let her help figure it out.

 

*Much of what is advised in this post relies on the assumption that one has access and choice in medical care. Unfortunately, in many places, this assumption is not a fair one. Due to factors like geography, insurance restrictions, a shortage of primary care doctors, too often patients cannot get care they are comfortable with. This could change with affordable comprehensive health care for all, an increase in the number of medical residents and incentives to motivate doctors into primary care. Consider ways you can advocate for these changes!

Learn More:

Why you shouldn’t use Google to diagnosis yourself

The classic article on how doctors think.

 

 

 

 

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7 Comments

  1. This is a great explanation of how a physicians brains work. Our training allows us the depth to see the possibilities in front of us and then simultaneously check them off/or add them to the differential.

  2. What a clear & considerate glimpse into our thought process as we are examining patients and thinking of those many branches of differentials you describe. Thank you for writing so eloquently

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