the patient is always right

                                                         The  patient is  always right!!

                                       By Vivek Hande

Having spent more than two and a half decades in contact with patients in one capacity or the other, I am convinced of the oft repeated statement , “the Patient is always right!”. Often, one may tend to disregard the complaints of the patient, if one cannot find a straight forward clinical correlate for the symptoms. One often finds the cause of the symptoms after spending much time, money, effort and considerable agony to all concerned. I have no doubts any longer that the patient is always right even though at times, the narrative of the symptoms may be bizarre , ridiculous , far fetched or improbable.  Very often what the patient tells you may be beneficial, for reasons other than clinical! The patient is always right, that is for sure…

Many years ago , when I was appearing for my Medicine Viva Voce  for my MBBS degree,  Francis , an Anglo –Indian was my patient . It was my first major clinical exam but he was a   veteran of examinations. I was desperately trying to get my very confused thoughts about the patient in some semblance of order.  Francis was rather amused with my efforts. He told me, “I am a case of Cirrhosis of Liver with Portal Hypertension. My Liver is enlarged which is not consistent with a diagnosis of Cirrhosis.  The examiner is going to ask you about the causes of enlarged liver in a case of Cirrhosis. If you answer well, he will ask you about Drugs which can cause hepatic damage. Don’t waste your time and efforts on other issues. Just concentrate on this and you will do well.”  I took a calculated risk and focused my thoughts on the matter suggested by him and put the rest on the backburner. Well, as predicted , the examiners were consistent with their line of questioning and I did rather well. Francis was proud of me and I had the fact reconfirmed-the patient is always right!

Then , there was this patient – Jagadish. He was a tall. well built strapping Jat. He cut a very impressive figure in his uniform . He used to suffer from repeated episodes of pain abdomen. He would keep coming back to the casualty and the Medical and Surgical OPDs. Each time he was evaluated in detail. The examination was always unremarkable. The investigations were always normal. He underwent repeated Endoscopies and Ultrasonographies and CT Scans and Barium  studies , but everything was always normal. Somebody though he was malingering and trying to avoid duties. He was evaluated by the psychiatrists as well, but nothing seemed to work out. He continued to be symptomatic off and on.  During the symptom free periods, he was absolutely normal and would play in Unit games and discharge all his duties well. However,  the pain would return and a couple of times , it coincided with his detailment  on temporary duties. He was branded a poor team man and nobody took his abdominal complaints seriously any longer.  He suffered from a loss of self-esteem and went into depression.He was hospitalized yet  again with pain abdomen and he was re-evaluated in detail. Virtually, every cause of pain abdomen in the book was looked up and he was evaluated for the same. He was finally diagnosed with Acute Intermittent Porphyria, a condition which does not produce too many clinical signs and shows up normal on almost all tests except the very specific Blood tests which have to be specially asked for. Jagadish was happy that a diagnosis was finally found – he was actually happier that he would no longer be regarded as a malingerer! The patient is always right!

And then there was this very astute clinician ,  much senior to me. He had a very sharp clinical mind and was rather proud of his clinical abilities. He developed a pretty chronic cough and he diagnosed himself to be suffering from Allergic Bronchitis and treated himself for the same. His cough persisted and his colleagues pointed out to him that he was losing a little weight. He assured himself and his colleagues that it was due to his strict dietary regime that he was losing weight. He was confident about his diagnosis and refused to show himself to anyone. One day , during ward rounds, one of his patients , a grey haired veteran of several hospital admissions and the proud owner of many morbidities told him, “ Doctor  Saheb, get your blood tested and get an X -Ray. You have Diabetes and I am pretty sure you have TB!”  The Clinician scoffed at the suggestion and moved on. But later in the day , when he was having his second cup of extra sweet coffee, the words of the patient kept ringing in his ear. He thought back about his symptoms and his problems. The next morning he gave his blood samples and got an X-Ray. His Blood Sugar was 385mg/dl and he had a   cavitatory lesion on the X-Ray. He responded to Anti –Tubercular therapy and his sugars gradually came under control with medication. Yet   again , in a manner of speaking , the patient is always right!

In our clinical practice we see all kinds of cases and all kinds of patients. As clinicians, it would always do us good to remember two things-Primum Non Nocere-First do no harm !  Also ,  the patient is always right!!!