As a Doctor, I Should be a Keener Observer and Notice the Pathology All Around Me

Since medicine is such a relationship based vocation, I find myself very often looking at my patients as people and not as clinical subjects. I have to keep reminding myself to do both.

I saw a cancer survivor recently whom I have known for ten years. I had referred him to a neurologist because of an atypical tremor. The neurologist diagnosed my patient with Parkinson’s disease but also pointed out that he had Horner’s Syndrome (droopy upper eyelid, small pupil and sunken in eye as we describe it in Sweden, lack of sweating on that side of the face, the way Americans describe it).

Was I ever humbled; I had seen the droopy upper right eyelid since I first met the man, but never had reason or, rather, been medically curious enough to check his pupils – the pupil on the droopy lid side is indeed smaller.

I have seen Horner’s Syndrome a few times, twice in the context of sinus cancer. One case was a woman who ended up with surgery that exposed the back of her eye socket and the back wall of her maxillary sinus, just like the pictures in my old anatomy books, the other was my own cat, who did not go through such radical surgery. Both died from their disease.

My Parkinson’s patient must have had the syndrome for a long time and no underlying disease has been found in his case.

I remember during a Harvard endocrinology course I started looking at passing strangers in downtown Boston every afternoon between class and dinner and wondering if they had acromegaly, polycystic ovaries, Klinefelter’s Syndrome, Cushing’s Disease or some other topic discussed that day.

But to be honest, I have dragged my feet many times before ordering the tests to rule such conditions in or out, almost as if I don’t want to insult my patients by suggesting their appearance is pathological.

That just isn’t right. I need to be a keen observer of clinical signs of possibly life altering diagnoses; I need to look at each one my patients not only for any change in their appearance, which I’m pretty good at, but also against my memory files of clinical syndromes that I, as their trusted family physician, should notice before some out of town specialist makes the diagnosis in a single appointment that wasn’t even for that particular abnormality.

Maybe that can be a New Year’s resolution of sorts.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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