Wednesday, July 28, 2004


I thought for sure that the patient I saw in clinic today was either going to kill herself or her mother by the end of the visit.

A shy, quiet girl in her late teens came in to our clinic with complaints of chronic abdominal distress. The primary care physician had made the presumptive diagnosis of symptomatic cholelithiasis and sent her to see a surgeon. I asked my usual barrage of questions trying to determine the etiology of her symptoms. At one point, I fell silent while examining her abdomen as I tried to piece together the puzzle to arrive at a diagnosis.

I've noticed that most patients become uncomfortable with silences. I guess sitting on a cold table in a doctor's office in various stages of undress makes one anxious to either hear a diagnosis, or hear the OK to get dressed. Whatever the reason, 90% of the time, patients will seek to fill that void by talking. The majority of the patients will reveal some useful aspect of their history that they've previously neglected to mention. Most physicians use this "silence" technique to elicit more data when they've run out of questions to ask. I, too, apply this method on occasion, but today, I was simply trying to arrive at a diagnosis.

As I was ruminating on her history, the girl's mother that had accompanied her to the office chimed in: "She has had a lot of gas recently."

To which the patient's eyes grew wide, glared sideways at her mother, and said through her clenched teeth in disbelief, "Mother!"

"And it smells really bad. Does that have anything to do with it?"

Now blushing a fierce shade of pink, "MOM!"

"What?" the mother retorted, "He's a doctor. He has to know all this."

I cocked my head slightly to the left, wondering if the noxious flatulence might have any relevance. Before I had a chance to say anything, the mother also exclaimed with a flair of eureka: "And she's been having a lot of diarrhea!"

The patient, now doing her best to disappear into thin air, groaned and hid her face behind her hands.