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The difficulty of taking a medical history from a
Dumb Patient

 

The following excerpt from one of my ER books illustrates the difficulty of obtaining a medical history from a dumb patient.  I do not wish to ridicule unintelligent patients, because many of them got that way through no fault of their own.  However, the etiology of their mental deficits is no consolation to doctors who treat such patients.  Obtaining a good history from stupid patients can be next to impossible, as you're about to see.

If you think that the pneumonia example was just an isolated instance of a disease that may be easily overlooked, let me give you a more general example of what physicians are often forced to deal with. The following is a verbatim account of a history that I once took on a patient. I wish I could say that this was an unusual case, but I've had so many similar histories that I've begun to get gun shy when I hear the phrase, "for a long time." You will see what I mean.

Dr. Pezzi: What seems to be the problem?

Patient: I be sick.

Dr. Pezzi: How are you sick?

Patient: I be sick all over.

Dr. Pezzi: What specifically seems to be the problem?

Patient: Everything be hurtin'.

Dr. Pezzi: How long have you been ill?

Patient: For a long time.

Dr. Pezzi: How long is that?

Patient: For a long time.

Dr. Pezzi: How long is a long time? A day, a week, a month, a year?

Patient: About that.

Dr. Pezzi: About what?

Patient: About that!

Dr. Pezzi: Has it been for a day?

Patient: Yup.

Dr. Pezzi: For a week?

Patient: Yup.

Dr. Pezzi: For a month?

Patient: Yes.

Dr. Pezzi: For a year?

Patient: Yeh.

Dr. Pezzi: For a decade?

Patient: That, too.

Dr. Pezzi: I'm having difficulty understanding just how long you have been ill. Can you be more specific?

Patient: I've been sick many moons.

Dr. Pezzi: You mean months?

Patient: Moons.

Dr. Pezzi: Are you referring to the lunar measure of time, often employed in the past by American Indians?

Patient: What?

Dr. Pezzi: How long have you been having this problem?

Patient: For a long time, Doctor!

Dr. Pezzi: Again, I need to know how long you have been ill. Can you give me at least a rough idea of how long you have been sick?

Patient: I've been sick since George got married.

Dr. Pezzi: I'm sorry — I don't know George, and therefore I have no idea of when he got married. Can you please give me an answer phrased in terms of time, like hours, days, weeks, and so forth?

Patient: Since Bill got his new car.

Dr. Pezzi: (Abandoning that train of questioning, realizing that it is fruitless). What medications are you taking?

Patient: The blue pill, the yellow pill, and the little white pill.*

* It has always amazed me when patients describe a pill by its color, and expect a doctor to know what it is without giving him at least a hint of why they are taking it. Although there are thousands of "pills" on the market, some people seem to think that the color of a pill is a unique identifier.

Dr. Pezzi: What are the names of the medicines?

Patient: I just done told you!

Dr. Pezzi: Why do you take them?

Patient: 'Cause I be sick.

Dr. Pezzi: I know that you are ill, but exactly why do you take them?

Patient: 'Cause my doctor gives 'em to me!

Dr. Pezzi: How long have you been taking them?

Patient: 25 years.

Dr. Pezzi: And you don't know why you take them?

Patient: Nope.

Dr. Pezzi: Are they for your heart? For high blood pressure?

Patient: I don't know.

(The interview continued in the same vein for another 15 minutes. At the end of that time, I still had no idea of what was wrong with the patient.)

I realize that this patient seems impossibly deficient in mental ability, but this was an actual case that I had during the mid-1980s. I wish that it was an isolated instance, but it's not. Every day in the emergency room I have patients who are pathetically unable to give a lucid history. Medical students are taught that a history is 80% of the diagnosis, meaning that the primary means of determining what is wrong with a patient is by talking to the person. The examination and tests help cement the diagnosis, but they are of secondary importance. I’d love to see Kellie Martin, who portrayed a bright medical student on the television show ER, deal with the above patient. It might not be politically correct, but it would certainly inject a dose of realism into that show. Instead of her usual brilliantly succinct case presentation, she’d say, "The patient’s been sick all over for a long time, for which he has received blue, yellow, and white pills."

The fact that a patient is "mentally challenged" is not an acceptable means of defense in a malpractice trial. In reality, it is obvious that there is an increased risk of a diagnostic error being made in such a case, when the patient can give a history that is no better than that which could be obtained from an earthworm. However, malpractice defense attorneys would be loath to suggest such a thing, as this might appear as if the physician were guilty of intellectual snobbery. Actually, it's just life in the real world. People who are stupid have an increased chance of doing stupid things, and making errors in judgement (as when they are driving a car, for example) for which they may pay dearly. It is an indisputable fact that they have a higher death rate, and no amount of liberal pressure to phrase their shortcomings in euphemistically acceptable terminology is ever going to benefit them. Actually, by attempting to mitigate the stigma of the intellectually vacuous, they are perpetuating their misery. A problem cannot be overcome unless it is recognized, accepted, and dealt with. Anyone's intelligence can be improved through effort. Coddling the incompetent merely predestines them to a life in which they will never reach their true potential.

Gee whiz, I was once incompetent enough that my sixth-grade teacher ridiculed me as “slow,” but I later graduated in the top 1% of my class in medical school. If I can do it (and I did), just about anyone could, so I am clearly no fan of Democrats or anyone else who think they are helping people by giving them things instead of giving them ways to improve so much they don't need hand-outs.

 

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