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Listen, Explain, Save Lives
By William Rohde, MD, MBA
Boston, Massachusetts
At the start of my medical training, I was taught that taking a patient’s history was the key to accurate diagnosis and treatment. The dictum that I was given as an intern on the Osler Medical Service at Johns Hopkins Hospital was simple: "The patient will always tell you ‘what hurts,’ if you know how to listen. As a picture of the patient’s current illness develops, you will rely on the expertise of other professionals— nurses, social workers, public health agents. Also, you should always consult family members and community resources who can help the patient communicate all the details necessary to establish a complete life history of the present illness."
The ‘diagnosis,’ that evolves from this process is not just a label, but a reference point for everyone who has anything to do with the patient. Although lab tests and x-rays help assess general health and determine the extent of the problem, health communication is the central diagnostic tool that leads to a treatment plan designed to address what may be literally hundreds of symptoms.
The multicultural population served by Johns Hopkins Hospital is severely impoverished and educationally deprived. Interns spend a lot of time translating ethnicisms. For instance, I recall a frail octogenarian, Miss Elly, report that she once had "fireballs of the Eucharist" which her pastor helped us translate as "fibroids of the uterus," and that she "dipped" (ate dirt from back home in Georgia) during her last pregnancy 50 years ago.
If we had relied solely on her rambling, disjointed medical history, it would have been easy to conclude that her current complaint of back pain most likely came from age-related degeneration of the spinal discs. Instead, we listened and observed, and this blissfully simple explanation didn’t last long. The nursing aide who washed her noticed and reported that our patient had deep "dents" in her temples - evidence of protein wasting caused by a chronic, rather than an acute, illness. She was unable to stand alone for the nurse who attempted to weigh her. By the time we got to rounds, and had verified each other’s observations, we knew that this was probably a chronic but life-threatening illness that had been overlooked most recently at another hospital.
As Miss Elly indignantly informed me, "I told those people that I thought I had that Smiling Mighty Jesus (spinal meningitis) just like what took my sister, but they didn’t want to listen." In this case, a spinal tap revealed the classic Red Snapper image of the tubercle bacillus. An x-ray of her abdomen revealed a huge calcified tumor with a hollow core, indicative of the original tuberculosis abscess acquired from the dirt that she ate. Her son was able to inform us that the dirt came from a cattle feed lot, where brucellosis could easily hide for years before being given a new home in Miss Elly’s digestive system.
So Miss Elly survived — because health communication was the touchstone of her treatment.
Dr. Bill Rohde is a consultant to corporations, executives and philanthropic organizations, specializing in crisis management, life strategy re-structuring, and substance abuse/mental illness. He has been on the Harvard Medical School faculty, managed a large private practice, given forensic expert testimony, and served as a court psychiatrist. He is currently pursuing a degree in healthcare communications at Boston University. You can email Dr. Rohde at drbillboston@msn.com. (Please include the word "consultation" in the subject line.)
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