Diagnostic Approaches – 2
This story is about a college student who came in with a fever. It's an illness that's easy to understand without too much confusion or stress. However, there are certain facts that everyone should be aware of, which is why this case was chosen.
The student had a high fever along with mild diarrhea, nausea, and a headache. Initial examinations made it seem like typhoid. To confirm if that's the case, a blood culture test was done, and the patient was admitted, starting antibiotic injections. The report would take three days to arrive. However, waiting until then wasn't an option. The treatment started based on clinical diagnosis. Later, when the report arrived, it would confirm if it was indeed typhoid and whether the current medication was effective or if any adjustments were needed.
If the correct medication is started for typhoid fever, it will take about 3-4 days for the fever to decrease. I made sure to explain this to them beforehand, as otherwise, they might repeatedly ask the doctor, causing unnecessary stress. After all, there’s always someone who will wonder, even after receiving the medication, why the fever isn't decreasing.
After three days, the intensity of the fever had reduced. The blood test report still hadn't come in. The following day, since the patient had planned to take a ten-day leave for a trip to the UAE, I discharged him along with others who were ready for discharge. I switched the antibiotic injections to tablets and reminded him that even after returning home, the fever might persist for another day or two, but there was no need to worry as long as the medication continued. He agreed and left for home.
After his trip, he returned to the clinic. His face didn’t show much of a change. When I asked about it, he started speaking in an accusatory tone.
"I told you, the fever could last another day or two."
"We went straight to a hospital in Thrissur," he said. "You can’t just deal with a fever like this."
"Okay, what did they say?"
"Well, that’s why we came here. The doctor here said it wasn’t typhoid, but a common viral fever."
That was the issue. They were implying that I had treated a non-existent illness. Many people believe that the final word comes from doctors at big hospitals, and there's a general societal assumption that their advice is always superior.
The patient's blood test results had already been communicated to me by the lab. I didn’t say anything further to them. I told them, "Your blood test report is ready in the lab. Please pick it up and come here."
When they brought the report, I asked them to open and read it. He read aloud:
“Salmonella Typhi Isolated.”
I asked, “Doesn’t that mean that Salmonella Typhi has been isolated from your blood?”
He nodded in agreement.
"Right, this is the bacteria that causes the disease we call typhoid."
At this, both the father and son were taken aback, their accusatory expressions slowly turning into ones of understanding and sympathy.
"I explained everything to you in detail that day. If you had been patient for a day or two, we might have avoided the need for another admission at a different hospital."
Without saying anything more, both of them quietly left.
All doctors working in small hospitals will experience such situations. A doctor's abilities depend on several factors—enthusiasm shown during study, sincerity, clinical exposure during training, the competence of the teachers, dedication after completing studies, efforts to keep up with new developments, and communication with doctors from other specialties, all of which influence a doctor's skills. However, there is no significant connection between the size of the hospital and a doctor's competence. In a smaller hospital, you might find doctors with lesser skills as well, and just working in a larger building doesn't increase a doctor's knowledge and abilities.
This way of thinking leads to certain problems. Some people tend to show unhealthy levels of obedience to diagnoses and advice given by doctors in big hospitals. If the diagnosis is 100% correct, that kind of obedience might be fine. However, all doctors are human, and even famous doctors can sometimes make mistakes in diagnosis. Perhaps later, a doctor in a smaller hospital may make the correct diagnosis or suggest certain tests that were missed before. At that time, if a patient says, "This is the disease as the doctor said, they’ll take care of it," and insists that the treatment from the new doctor is sufficient, they might be shutting the door to proper diagnosis and treatment.
Let me give two examples. Once, a patient who had been diagnosed with liver cirrhosis (liver inflammation) by a gastroenterologist came to our hospital. The doctor had advised a blood transfusion because the patient's blood count was low. Upon reviewing the old reports, I couldn’t find any evidence confirming that the problem was liver-related. However, after examining the patient, I noticed symptoms of blood cancer. I discussed my doubts with the patient's son, and fortunately, he agreed to further tests. After conducting a bone marrow test, we confirmed blood cancer. Unfortunately, due to the delay in diagnosis and the patient’s age, we couldn’t save the patient.
In another case, a patient who had previously been diagnosed with epilepsy and was taking medication, came to the clinic because of recurring symptoms. After questioning, I suspected that the patient’s condition was actually syncope, a type of fainting caused by heart issues. After checking the patient’s pulse, I found it was dangerously low, indicating a complete heart block. We then implanted a pacemaker, which resolved the patient’s issues with fainting.
The point here is that no one’s word should be considered the final word. When visiting a doctor, go with an open mind, free of prejudices. Be sure to share your symptoms and treatment details honestly with the doctor. If the doctor raises any doubts, listen to them carefully rather than dismissing them. Don’t dismiss the doctor by saying, "I’ve already been treated by another doctor," especially when it comes to complicated matters. In the end, it’s important to keep an open mind and even consult with the previous doctor if needed.
Let me end with an example from when I worked in an emergency department right after completing my MBBS. A retired soldier came to the hospital in the middle of the night with his son. When I asked what the problem was, he gave a very strange complaint.
“Doctor, my heart rate is 90.”
“What’s the problem with that? Do you have chest pain or difficulty breathing?” I asked.
“No, nothing like that.”
“Then there’s no problem with a heart rate of 90,” I replied.
“No, I’m a heart attack patient. My doctor told me that my heart rate should be between 65-70. I check it many times a day, and it never goes up to 90.”
“65-70 might be better for you, but it doesn’t mean that anything above that is an illness. The human body isn’t a machine, and your physical activity, mental stress, etc., all influence your heart rate. Checking your pulse frequently like this will only cause unnecessary stress, which will increase your heart rate. Stop checking it constantly and enjoy the beauty and peace of life,” I said.
He was very upset and replied, “You don’t know anything. My doctor has told me about heart rate. What do you know?”
I was frustrated by his response. The son tried to calm him down, gently persuading him, and gave me an apologetic look. Then the patient stormed out, angrily stomping his feet on the floor.
It’s true that heart rate should be kept at a lower level after a heart attack, and the doctor explained this to him. But because of his excessive obedience to his previous doctor, he was not willing to listen to anything else.
The lesson here is clear: keep an open mind, listen to the doctor, and don’t blindly follow any advice.