Essential Reading

No, I am not suggesting that consuming this article is critical, although the advice at the end may be. Rather I am referring to Samuel Shem’s The House Of God. This humorous novel written under a nom de plume by Dr. Stephen Bergman, a psychiatrist, is a fictionalized account of the residency training of the main character, Dr. Roy Basch, under the tutelage of “The Fat Man,” purportedly based on the Beth Israel Hospital in Boston. The witty narrative focuses on the foibles of human behavior, good and bad. The Fat Man teaches Dr. Basch thirteen rules, the last of which states: “The delivery of good medical care is to do as much nothing as possible.” And sometimes that is exactly what is needed, but often turning over every stone is the way to go.

The practice of medicine is primarily an exercise in logic and deductive reasoning. In The House of God, our hero learns that if one hears hoof beats, think horses, not zebras. In other words, common things are common – one is unlikely to ever find hen’s teeth or rocking horse manure. But rare problems do arise in medicine and if one or more symptoms puzzle a doctor because they do not fit a common disease behavior, a less than utterly diligent physician might miss the warning signs. But there is a good defense against such laxity – believe the patient. Always believe the patient.

If a gentleman states that he gets a pain behind his eyes when he passes urine in his bathroom, the fancy way of characterizing this would be retrolental micturalgia. I cannot think of a disease process that could cause this but maybe some careful questioning might reveal that deteriorating distance vision is causing squinting while peeing as the source of the discomfort. Always believe the patient.

Recently, I learned of two patients who had strange symptom complexes and other doctors had dismissed both individuals as being “hysterical,” a word which derives from the Greek hystera, meaning “womb.” The ancients believed that only women could be “hysterical” and that this was due to a defect in the womb, both of which are obviously ridiculous ideas. Both of the referenced patients had bizarre neurological symptoms and both turned out to have rare – and very real – medical problems and ended up dealing with two problems, the disease itself and the dis-ease of interacting with the medical profession.

So how is this relevant to you? If you notice a new symptom make sure you document, in writing, everything about it. For instance, if a pain, note:

  • What does it feel like (gripping, stabbing, aching)?
  • Where is it located?
  • When does it occur?
  • Does anything provoke or improve it?
  • Is it associated with other symptoms?

Similarly, for other symptoms, characterize as much as possible before going to your doctor – he or she is a human being and prone to the same distractions and errors we all make, so try to make their job easier. When a physician takes a history, he or she will ask questions that follow a format; completing this before the consultation might stimulate the doctor to ask a key question or order a specific test.

Chief Complaint

As above, note each symptom and write everything down so that you do not forget to mention something that could be key.

Past Medical History

  • Include every operation you have undergone.
  • Note all medicines taken now or in the past.

Family History

  • Ages of parents, grandparents, siblings and if deceased, at what age and with what causes and medical history. Genetic components of diseases are important and we are learning more about this element every year.
  • Any other family members with medical problems?

Social History

  • What work do you do and have you done in the past? This could expose work environment factors that can cause disease.
  • Where have you traveled in the world? This might lead one to think of exotic infectious or parasitic diseases.
  • Do you now, or have you ever smoked? I have frequently had patients state they did not smoke, but further questioning revealed they used to be a heavy smoker.
  • Do you now or have you ever drunk alcohol? How much? Be honest. For instance, heavy alcohol consumption can cause issues with the nervous system and many others; failing to disclose consumption might prevent the doctor from thinking about such things.
  • Do you now, or have you ever taken recreational drugs?
  • Do you have any allergies?
  • Diet? Anything that you eat – or don’t eat – can impact human health. For instance, some Chinese herbal medicines have been contaminated with heavy metals that can be very toxic.

Review of Systems

Note down any aberrations you have experienced, however silly you think they might be. Here are some examples:

  • Cardiovascular: chest pain, palpitations, cold feet
  • Respiratory: shortness of breath, waking up breathless, feeling breathless lying flat
  • Neurological: changed sensations, transient loss of vision or weakness, issues with hearing, vision, taste, smell, balance
  • Urogenital: frequency of passing urine, problems passing urine, changed color or smell, pain, issues with sexual performance
  • Gastrointestinal: changed appetite, weight loss or gain, bowel habit and any changes, abdominal bloating, nausea or vomiting.
  • Musculoskeletal: aches and pains, weakness, joint stability

Equipped with this information, your personal physician will conduct an appropriate examination and may order relevant tests and will be best positioned to help you. If, however, you have any level of concern remaining after this interaction, do not be shy about asking for a second opinion. A good doctor will never be offended and after all, this is your health we are talking about!

In medicine we use a lot of Greek words, including pan, which means “all” – for instance, pancytopenia means every type of cell in the blood is depleted. In The House of God, we learn of patients who are pan positive, meaning they have every symptom known to man. Yes, there are people who imagine physical problems, but in my experience, the old adage that “the customer is always right” applies to medicine just as much.

Please be your own advocate and push for a resolution of your problems, and remember, first sort out your health and only then worry about the flight medical issues.

Jonathan Sackier

Dr. Jonathan Sackier is an expert in aviation medical concerns and helps members with their needs through AOPA Pilot Protection Services.

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