Listen to Your Gut
By Andrew Ellsworth, M.D.
The patient knew something was wrong. After appointments with several specialists, multiple scans, and tests, she was given a diagnosis. Still, she felt certain something was not right. I sat down with her and listened. We repeated a test she had a year prior, and this time the test garnered a different result. There was a tumor growing. She listened to her gut, she persisted and with an accurate diagnosis she got the medical care she needed.
Usually, it does not help to repeat a medical test. Nine times out of ten the result is the same. However, if as a patient, you get that feeling that something is amiss, seek out answers and find someone who will listen. That does not mean you need every possible test. Tests are costly. They are only a tool and using the wrong tool can cause more harm than good.
Physicians are adeptly trained in the application of the tools of medicine. Throughout college, four years of medical school and another three or more years of residency training, an M.D. or D.O. invests over 10,000 to 15,000 clinical hours while learning the art of medicine. Ideally, as physicians gain experience and confidence, we learn to discern when a test is needed, and how to avoid an unnecessary test.
Most importantly, a well-trained physician learns that listening to the patient history is a more powerful tool than any test. The history is the story of the patient’s current and past symptoms as told by the patient. It does not come from the chart, is not in a textbook, and cannot be determined by a blood test or CT scan. To obtain it, a physician must listen.
Unfortunately, physicians often interrupt a patient within the first 10 to 15 seconds of the visit. Pressures from time, from documentation, from insurance companies, and from the next patient that is waiting can contribute to the detriment of the interview. However, with careful listening and guidance from the physician, the patient will frequently provide all that is needed to reach an accurate diagnosis.
We can all learn more by listening. Whether listening to our bodies, our family, our friends, or even our adversaries, it is time well spent. When we take the time to listen, we are one step closer to the truth. You’ll feel it in your gut.
Andrew Ellsworth, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.
Sometimes a Diagnosis is Skin Deep
By Kelly Evans-Hullinger, M.D.
Recently I saw a patient who had experienced two consecutive days of pain in his right upper abdomen. I questioned him, looking for clues of gallstones, liver mass, or maybe an ulcer in the small bowel, but his answers did not fit my expectations. The pain was located under his right ribs and radiated into his back, just as I would expect of gallbladder disease; but it was not triggered by eating, and the way the patient described the pain did not fit the profile of an abdominal disorder. Then, a lightbulb went off; I needed to look at his skin.
I examined his right back, and sure enough there it was: a cluster of red, blistering, lesions that the patient had not yet noticed. This was not gallbladder or liver disease; it was shingles.
Shingles is a skin eruption caused by a reactivation of the varicella zoster (or chicken pox) virus. In people who have had chicken pox earlier in life, the virus goes dormant in a spinal nerve. For most of us, it never again causes a problem, but in some people the reactivated virus can spread to areas of the body following the distribution of that spinal nerve, causing a painful blistered rash which looks like chicken pox.
The pain caused by shingles often occurs prior to the visible skin outbreaks making it easy to misdiagnose. In my few years of practice I have discovered shingles in patients complaining of ear pain, abdominal pain, and low back pain.
When administered early, antiviral medication can limit the duration of shingles and reduce the risk of post-herpetic neuralgia, a pain in the affected nerve distribution which lasts long after the rash resolves. At its worst, post-herpetic neuralgia can be a debilitating and life-long condition.
Fortunately, we have a highly effective vaccine that greatly reduces the risk of having shingles. The current shingles vaccine is FDA approved for people 50 and older and is much more effective than the previous version of the vaccine.
Thankfully, widespread childhood chicken pox vaccinations started in the late 1990s so decades from now, shingles may be a rare relic of the past in the United States. Until then, I will always remember to look skin deep when investigating a patient’s new pain.
Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.
With A Little Help
By Debra Johnston, M.D.
As a primary care physician, I walk with my patients as they face many of life’s challenges. Facing the diagnosis of dementia may be one of the hardest. Any chronic illness involves loss, but dementia threatens the loss of not only ability and independence, but of the very self.
It is important to realize that people with dementia can have rich and rewarding lives. For most patients there is an initial period where their losses are mild. There is likely time to work on that bucket list, to enjoy hobbies new and old, and laugh with loved ones, even if you are eventually playing Hearts instead of Bridge. While we grieve the loss of what was and of what we expected for the future, we can lose sight of what remains. It is a very human and very understandable response, but it can also waste precious time.
The early stages of dementia provide an important opportunity for patients and the people who love them to consider the future. People with dementia face the near certainty that they will eventually be unable to make decisions for themselves, decisions in keeping with values and preferences they have held all their lives. Developing an advance directive is something many of us put off for some nebulous “later.” Doing it now can ensure that our wishes are known and honored when we can no longer express them. It is also an incredible gift to give our loved ones. I’ve lost count of the number of times I have watched a grieving family clutch that piece of paper to remind themselves that “this is what mom wanted” as they make difficult decisions.
Early on after the diagnosis is also a time to nurture relationships that will provide support for the person diagnosed with dementia and their care partner going forward. Professional help is available and sometimes the best option, but community support is invaluable, and irreplaceable. Family and friends can offer support and social contact, be it a cup of coffee and a listening ear, or a friendly round of golf, just like the old days. As the disease progresses, the support might be more substantial, such as a ride to the grocery store for someone who can no longer safely drive or keeping an old friend company so their spouse can go to the doctor, or get a haircut, or just take a break.
As we have seen during the pandemic, suffering from any disease in isolation is lonely and frightening. Regardless of the diagnosis we might face, we can take the time now to make our wishes known and build up our community of family and friends. Ask for, and offer, support. As the old Beatles’ song suggests, we get by with a little help from our friends.
Debra Johnston, MD is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook, featuring On Call with the Prairie Doc® a medical Q&A show streamed most Thursdays at 7 p.m. central.
Give Yourself Permission
By Jill Kruse, D.O.
Whenever someone is admitted to the hospital, they are asked to stipulate their “code status.” Levels of code status include full code, meaning resuscitate and intubate if required; as well as various combinations of do not resuscitate (DNR) and do not intubate (DNI). In simple terms, a code status clarifies what you want the medical team to do in the event your heart stops or if your heart goes into a rhythm that is not compatible with life.
This question is often interpreted as follows: if you are about to die, do you want the medical team to do everything they possibly can to keep you alive? We might also allow ourselves to pose and interpret the question from a different perspective: If you are about to die, do you want permission to pass away peacefully?
When discussing code status with my patients, the answer I often get is, “Of course I want to live, do everything you can to save me.” TV and movies mistakenly portray emergency lifesaving measures working most of the time. In real life, attempts to resuscitate are not as successful. A review of more than 29 different studies involving 400,000+ people over the age of 70, show that only 19 percent survived to be discharged from the hospital. The odds were even worse for those in their 80s or 90s with survival rates of 15 percent and less than 12 percent, respectively. Of those who survived, less than half returned to the same status of living they enjoyed prior to the code. Most ended up not able to care for themselves independently.
Another common response I hear is, “Do everything if you think it will work.” Doctors are incredibly optimistic. We are trained to fight against the odds to save lives. Unfortunately, no one can predict the outcome of a code. That is like asking if a slot machine will win before we pull the lever. Sometimes we hit the jackpot and the person does fine, goes home, and everyone is happy and grateful. Other times, like most slot machines pulls, we are forced to admit the loss.
The best person to select your code status is you. There is no “right” answer, there is only your answer. Give yourself permission to make this decision with a calm, clear mind before you are in crisis or admitted to a hospital. It is not in your best interest to make a rushed decision. Nor is it fair to force it upon your loved ones in an emergency room as your health is rapidly declining.
It is okay to give yourself permission to change your answer over time as different circumstances arise. Share your answer with your family and your doctor. Then give yourself permission to be at peace with your answer.
Jill Kruse, D.O. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.