Time Well Spent

A famous physician author once penned, “the best medical student only triples your work.” While this cynical statement does have potential to ring true, I have also experienced the exact opposite–when having a medical student in clinic saves time, spares the patient unnecessary work up, and saves health care dollars.  Recently I had one of those moments. 

On my schedule was a 48 year old female who was coming in for “persistent fevers and abdominal pain” per intake notes; I had not seen her before, and I thought it might be interesting for the student to evaluate her first.  We reviewed the chart together and found that she’d been seen multiple times in the past two months for the same symptoms, including two ED visits and multiple clinic appointments with essentially a negative evaluation, except for one positive covid test four weeks ago. I started to consider fever of unknown origin, which is an interesting topic; I printed out a teaching handout on the differential diagnosis and approach to the workup, handing it to the student and asking if she’d like to see this patient. She nodded, and said, “Wow, this seems like a really complicated case.” I agreed, and mentioned it was puzzling that the fevers seemed to predate the covid infection. In my mind I was also thinking, what if this ends up being nothing?  I could not find a documented fever or an elevated white count upon chart review.  Some of the physician notes had language that implied a functional or psychosomatic component, such as, “no medical explanation for multiple symptoms.”  I also saw that this patient needed a Spanish interpreter, and since the pandemic, our interpreters have been virtual on a tablet device attached to a pole in the room; less than ideal, compared to in person interpreters, in my opinion. 

I instructed her to go in while I saw the next patient who had arrived early and was already roomed, a tag team of sorts. I finished up a return visit for hypertension, then an established patient physical, and grew concerned when I saw that the student was still in the room with our FUO patient, over an hour after the start of the appointment.  Still, I wanted to allow her space to form her own impressions and ideas, so I gave her a little more time.  Thinking about fever and abdominal pain, I began to tee up orders that would reflect a potential workup; repeat labs, urinalysis, CT abdomen, quite a long list.  All the while noting that her vital signs were stable and her temperature was 98.2 degrees Fahrenheit which was again, quite puzzling.

My student emerged from the room and found me at my desk.  “So, what did you find out?” I asked.  Imagine my surprise at her response:  “That visit took a couple unexpected turns. I think she’s having menopausal hot flashes. The patient said nobody has ever explained menopause to her before. She hasn’t had a period in eight months, and has been experiencing mood swings. She describes her “fevers” as feeling warm, flushed, in a sudden wave, and these waves often wake her up at night feeling drenched in sweat.” She then went on to provide more detail in terms of the lower abdominal pain, which sounded very much like chronic constipation. Almost sheepishly, as she spoke, I was hitting “cancel” on my orders, including the CT abdomen, the multiple labs. 

Of course, the student had also taken a detailed history for infectious, rheumatologic, and malignant symptoms, all of which were negative.  Her willingness to spend extra time with the patient, take a thorough history, and provide some basic education on menopause–through a virtual interpreter, nonetheless–led to a diagnosis and treatment plan that was completely different from what I had imagined.  It gave me pause to consider the implications of this encounter; how spending more time with a patient and taking a detailed history, which is what they teach us in medical school, is truly a better diagnostic intervention than ordering a large battery of tests. My student also offered this astute observation: “I am surprised that in clinic, your schedules do not extend the appointment times to allow for an interpreter.” I couldn’t help but wonder if the fact that she needed an interpreter hindered the ability to arrive at the correct diagnosis earlier in the evaluation.  Perhaps the patient calling her own symptoms a “fever” was in part a language barrier that led to physicians anchoring on potential diagnoses, or attempting to rule out others, without considering vasomotor symptoms associated with menopause.

At the end of the visit, we decided to order an FSH, which I explained was typically not necessary to confirm menopause, but if it prevented a large and expensive FUO workup, it could be worthwhile.  It came back elevated, confirming our clinical suspicion.  And I mentioned to both the student and the patient that there were medications to consider for treating hot flashes. The patient seemed relieved to finally have an explanation, and scheduled follow up with her usual PCP to discuss further.

In the medical literature, it has been quoted that 80% of the time, the correct diagnosis can be found via history alone. This makes history taking a very powerful tool, and we should take every advantage of it, including allowing enough time for the interaction between doctor and patient. Maybe not a full hour, but certainly, this case illustrates the impact it can have.  And I also considered the DEI implications; I can’t help but wonder about the impact of the language barrier, the need for better patient education, and our current lack of in person interpreters. We will continue to push forward on the vital topic of interpreter access, but in retrospect, when I was able to hit pause and allow my student over an hour with our patient, I can say in retrospect, it was truly time well spent. 

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