Thomas W. Shinder, M.D.
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Your Health Matters

By Thomas W. Shinder, M.D.

    
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Your Family History: Helps and Hindrances

Managed care has changed the entire nature of the physician/patient relationship. Traditionally people spoke of "their" doctors because they felt a connection with the physician who cared for them. They shared thoughts and feelings and concerns with their physicians, regardless of whether there was any relationship to what was ailing the patient at the time. This is no longer true.

The emergence of Health Maintenance Organizations and other similar managed care entities has created a situation where the luxury of time no longer exists. With the "bottom line" (time = money) always staring the physician in the face during patient encounters, the challenge of obtaining the patient's history in a timely fashion has been increasingly difficult.

Typically, the first visit to a physician includes what is called the "history of present illness". You, the patient, are asked to expound on what is ailing you, and the doctor tries to ask questions based on the history that you give. This is often referred to among doctors as the "guided interview". By asking questions based on your responses, the physician is able to test hypotheses regarding what may be the source of your problem.

This process of history taking is considered by medical educators to be by far the most important of all the diagnostic tests. From this information which is garnered during the history-taking process flows all the other objective diagnostic studies such as MRIs, blood tests, x-rays, and CAT scans.

Because of this profound dependence upon the medical history, it must be accurate. The doctor must hear and understand what you, as the patient, are saying, and you must be able to clearly explain in natural language your concerns and your answers to your physicianís questions.

This is where the family comes into play. There are scenarios that play out in physicians' offices throughout the world everyday:

You go to your doctor's office with a headache. The physician asks you questions such as "where in your head does it hurt?" and "is it a throbbing pain or a dull aching pain?" During this process, the doctor is trying to assess what some of the possible causes of this headache might be, making sure that life-threatening considerations and the most common causes are taken into account first.

In this typical scenario, after months of treatment, the headaches donít seem to be getting any better. The MRI and other diagnostic tests have all eliminated potentially serious causes of the headache. Youíve tried several different types of medicines, none of which has had any long-lasting benefit. Both you and the physician are becoming frustrated at the lack of results, and the managed care organization wants to know where all of its money is going, and an explanation for the fruitless perseverance on treating your headache.

What's next? The physician may ask you to bring your husband in for the next visit. He might have some observations that can be helpful in assessing the cause. Patients donít typically bring family members along to doctor appointments, but you are willing to comply with the physician's request.

During the next visit, the doctor notices that you and your husband donít seem to agree about anything, and perhaps your husband has a browbeating and disparaging attitude toward you that is displayed during the interview. He says to the physician that thereís nothing wrong with you and that youíre just lazy and trying to get out of doing things by "pretending" to have a headache.

Is it any wonder that a woman in this situation has chronic headaches? Psychological stress and a sense of hopelessness are perhaps the most common causes of chronic daily headaches (appropriately called stress headaches) in the industrialized world. If the physician had asked to speak to a family member sooner, perhaps months of nominal treatment approaches and potentially dangerous medications could have been avoided.

Well, then, why didnít the physician ask for a family member to accompany the patient earlier? Some insight could be gained from the second scenario:

An elderly couple comes into the office. The woman is concerned about her lapses of awareness that lead her to walk the streets and fall onto the pavement, only to be found later by her husband, who brings her home on each occasion and cares for her until she returns to her normal level of awareness. These falls have bruised her face, arms, and legs.

This history of episodic alterations of consciousness with amnesia for the events during the lapse is most consistent with either seizures (epilepsy) or stroke-like phenomena. The woman is deferential to her husband and lets him do most of the talking; he is also a retired family physician who comes across as knowledgeable and is able to give a perfect history for his wife.

An MRI reveals some minor changes consistent with this womanís age. The EEG fails to demonstrate any significant seizure-like activity, and tests of the blood flow in her brain and heart fail to reveal anything which might explain her symptoms. Her husband dutifully accompanies her and answers the physician's questions with perfect and precise medical terminology.

Something is missing. The doctor asks his nurse to bring the patient in alone during the next visit. During this visit, the woman breaks down and starts crying. She explains that her husband has a drinking problem and that he beats her up, but she didnít feel that she could tell the truth in front of him, and even now fears repercussions for sharing this information.

Had the physician insisted on seeing the patient without her husband's accompaniment earlier, unneeded, expensive, and dangerous tests would have been avoided. Had she never been able to interact with the physician alone, the abuse -- both by the husband and the medical system -- could have continued indefinitely with the potential of tragic results.

The family history can confound or confirm a diagnosis. These examples were drawn from my own clinical practice, and all physicians can share similar stories. These are some of the considerations you should keep in mind, and perhaps you should take the initiative when your doctor doesnít think of bringing in or eliminating an observer.

By doing so, youíll be taking control over your own care. And during these times of profit-based medicine, itís the only way to make sure you get the care you need. Itís important, and itís vital, because Your Health Matters.



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TOM SHINDER is a neurologist-turned-computer-professional who is involved in consulting and software training for a large nation-wide company in the Dallas-Ft. Worth metropolitan area.

For comments to the writer mail to:shinder@dallas.net



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