Saturday, February 22, 2014


I am a list maker.  

I suspect I must have a touch of ADD or OCD or some other letter soup. I've ALWAYS made lists.
My mantra during college was, "What's the plan?"  If there wasn't a coherent and cohesive plan for something, anything, I always felt out to sea.  My Mother-in-law made fun of me one day, saying, "You can't plan everything, Michele." 

One of the things magazines tell you to do before a doctor's visit is to "make a list of questions to ask your doctor."
In my experience, most doctors HATE lists. They find them to be...overwhelming.

 I, on the other hand, LOVE lists.  Lists are wonderful.  I have a PLAN when I have a list.  I don't have the last minute, hand on the doorknob as I'm leaving the room, "Oh, doc, I forgot to ask you about this crushing chest pain" experience that totally blows my schedule to bits. 

Just because you have a list, doesn't mean we need to deal with all of the questions at that visit. 

A list gives me a road map.  It allows me to triage a patient's concerns.
BUT....Be prepared to hand over the list to me.  It works better if I can look at the list and get an idea of the following:

1. What are the three most important things on this list? In fact, please highlight those for me beforehand.

2. Are there some super SCARY things that need to take priority, putting everything else on the back burner? 

 3. Are there some super simple things I can deal with in one or two seconds?  Like looking at a mole?

You see, doctors think differently than other people.  We think about what can kill you, first;  what can really mess you up, second; and what is annoying but not likely to do major harm, third.  
Lastly we think about problems that are not concerning at all.  

We want to address problems in that order, too. But, we need your agenda, first. A lot of times people save the worst for last, trying to talk themselves into bringing up the topic they're most afraid to broach.

 It's magical thinking. "If I don't talk about it, nothing bad will happen."  


Burying your head in the sand and ignoring things is always a bad idea.

Telling your doc the biggest problem when your appointment time is almost over is always a bad idea.

You don't want an annoyed, rushed person dealing with a potentially life threatening issue at the end of an appointment!  You want a laser focused, un-distracted, un-rushed physician, using all of their skills to deal with your problems.

So, screw up your strength and courage.  Write down your list of problems and complaints.  List them in the order you're most concerned about, highlighting the top three concerns.  
Don't expect to get through a list of 10 complaints in one visit. Have realistic expectations of time management. 

Don't be afraid to tell your doctor that you are terrified that you have cancer.  Or a brain tumor.  Or heart disease.  If we don't know your concerns, we can't address them.  



Tuesday, February 11, 2014


People come to the office all of the time apologizing for looking on the Internet and reading about medical conditions. I must be a weirdo amongst doctors, but I don't mind it when people try to learn about their health problems.

BUT, one of the more difficult problems I have is getting people to understand that many medical problems have the same symptoms and that having a cough does not necessarily mean that you have lung cancer or Goodpasture's syndrome.

In medical school and residency, it is pounded into to us that:

 "Common things are common. When you hear the sound of hoof beats think horses not zebras. "

 Photo credit:

When people look things up on the Internet, they often think zebra not horses.

In order for doctors to learn how to differentiate  symptoms into disease states or illnesses, it takes a long period of training. There are four years of medical school and then anywhere from 3 to 10 years of residency training, depending on what field you go into.

The First year of medical school is learning all about normal. You dissect the human body, breaking it down into every single nerve, artery, vein, lymph vessel, muscle, organ, and fluid. Then you look at all of it under a microscope, learning what "normal" looks like. You  learn the normal functions of every part of the human body in Physiology.

The Second year of medical school is learning about all that can go wrong in the body. You learn about "abnormal".
 We learn about infectious diseases, cancers, autoimmune diseases where the body stops recognizing itself and attacks normal tissues, making one sick.  We learn about how these diseases affect every organ system.  We learn what theses diseases look like under a microscope, and what people who have these diseases look like.

In the twenty first century, second year students also start learning how to talk to patients.  They learn how to ask open ended questions.  They learn how to do a "Review of systems" so they don't forget anything.  A Second year student  has a limited fund of knowledge so in order to get enough clues to make a diagnosis, they need to ask about every single system.  One will find that all well trained physicians do this same thing so they don't miss any clues.

In the Third year of medical school, you are handed a white coat and a stethoscope, taught how to take a complete history and physical, and then are expected to go out and learn. You learn to take a whole bunch of symptoms and make a diagnosis . Unless you have a really good attending or resident teacher, it's very hard to learn how to do this.

Part of the training is being exposed to a large number of sick people, usually in the hospital, sometimes in the office setting.  The student takes a history and physical, tries to put it all together, presents his findings to an attending or senior resident, and gets shot down.  Getting shot down is not a failure.  It is a learning experience.  

 Learning  how to interpret the story of a patient into a correct diagnosis is a skill.   It isn't magic. 

It requires a deep fund of knowledge acquired by reading and memorizing, and it requires  deductive reasoning.  

 It requires one to ask "WHY?" a lot. 

 "Why is the potassium low?" "Why is his skin yellow?"

Asking "Why" instead of just treating things as they pop up, often is the difference between an adequate and an excellent physician. 

A student spends time working in most general specialties in third year.  Internal Medicine, Surgery, Family Medicine, OB/Gyn, Psychiatry, Pediatrics are some of the main specialties in third year.

Fourth Year is spent in sub-specialties like ENT, urology, cardiology or pulmonary, learning in greater depth, and often one on one with an attending, or fully trained, physician.

Peptic ulcers, gallbladder disease, hepatitis, pancreatitis, pancreatic cancer, stomach cancer, colon cancer, heart attacks, collapsed lungs, fluid around the heart or lung--All  can cause the exact same symptoms. 

The trick is knowing which questions to ask, which tests to do, and which physical exam findings to look for, and then to properly interpret what you have found. 

Proper interpretation is learned through medical school training, residency training, and experience.

You hear people say, "Dr. so-and-so is a great diagnostician."

 That means that Dr. So-and-So is extremely good at doing a very thorough history and physical, and then going through all of the possible diagnoses that could be wrong and figuring out the right one.  

It is a skill and it can be learned.

Reading on the internet about your diseases or symptoms is a great place to start.

 Many of my patients have come in BECAUSE they read up on their symptoms and realized that something might be seriously wrong, and often, they were right.   

I find it helpful, also, for people to do reading on reputable web sites AFTER given a diagnosis.

They learn how to take care of their diseases, how to stay healthy, how to eat right and exercise, etc.

One of the challenges I face is "Medical Student Syndrome." 

ALL medical students become convinced at some point that they have cancer or some horrible illness.  Usually it is something they are learning about at that time.

"But DOC!  I have all of the symptoms of (put terrible life changing illness here)!"  

Don't succumb to Medical Student syndrome.  Patients who read about an illness, often get "stuck" on a diagnosis, for the same reason Medical students do.

They don't know enough about ALL of the illnesses that can cause the SAME EXACT symptoms.  If you have symptoms, come in and tell me about them so we can interpret them in a framework that comes from a deep fund of knowledge and experience!