Life would have been a lot easier if I’d been taught to use a stethoscope properly in medical school.
Yes I was taught the usual stuff about bells and diaphragms and I agonised trying to hear murmurs, rubs, snaps crackles and pops. No one told me, though, that it was really a tool to block your ears during a hectic day - something that could give you a precious minute our two of calm in the hurly burly of a busy surgery. ‘Listen to the patient and they will tell you the diagnosis’ was a regular mantra, but occasionally you do need the patient to be quiet.
I was enjoying one of those blissful moments of peace during a particularly baffling consultation. The patient had a constellation of symptoms that didn’t appear in any textbook I’ve come across. Stethoscope in ears, I was staring vacantly at the floor in a state of zen-like calm, when the carpet started to transform bizarrely before my eyes. The drab, functional pattern suddenly became beautiful, luminous and three dimensional. No mind enhancing substances were involved. The effect was like one of those magic eye pictures when a flat pattern becomes 3D as you stare at it vacantly. I’m easily amused and the illusion added an unexpected, simple pleasure to a mundane day.
It is commonly taken for granted that medical diagnosis is an objective process of recognising patterns. The patient has a symptom and the doctor then takes a focused history, examines the patient, does appropriate tests and comes up with a definitive diagnosis. Or in modern cutting edge general practice the patient appears with a problem and the doctor fills in any missing information from the QOF templates, then if there is time, proceeds as above. Like a game of medical Cluedo, if they have enough cards the clever doctors can throw them down with a flourish and confidently announce that it was Colonel Cholesterol that did it with a Plaque in the Coronary Arteries. But the same, apparently objective patterns can be perceived in dramatically different ways by different people and at different times. Occasionally things are clear cut, but often they are subtle like moving patterns made by shifting sands.
As the treatment of major illnesses like infections, diabetes and cardiac problems has got more successful, we tend to see more dis-ease rather than disease. Patients present with more subjective, vague concerns about their internal world.
Conditions like fatigue, chronic pain unhappiness and stress make up more of the mix. People are not uniform biophysical systems and these concerns will be interpreted in a myriad different ways by both patients and doctors. Some patients can happily live with something like a dodgy digestion whereas other patients will spend a large chunk of their life circulating through various clinics and investigations hunting for a solution. The more time you spend in this medical merry-go-round the more likely that you will find something wrong.
I’m intrigued by the fact that despite medicine getting more technologically successful patients satisfaction has not increased as much. In fact I sometimes get the impression that patients are more dissatisfied despite these advances. The disparity between the uniform objectivity assumed in the classic medical model and the often blurred, subjective reality plays a large part in this conflict. Trying to shoehorn symptoms in to what we already know doesn’t always work and sometimes staring blankly will let the patterns reveal themselves. In the frantic business of the day we need time to block off the outside world and have time to stare. My stethoscope will stay as an important tool to help me do that.
- © British Journal of General Practice 2012
