Listen to the patient

Sir William Osler famously said: “Listen to the patient. He is trying to tell you what ails him.” He meant it figuratively, of course, but it can also be literally true in the most literal and concrete ways, as I learned during my fourth year of medical school.

I was spending 6 week doing a ‘rural rotation’ in a National Health Service Corps clinic in Etna, California, a far cry in every respect from Strong Memorial Hospital and the University of Rochester School of Medicine. The daily fare was mostly straightforward: minor trauma, skin rashes and infections, respiratory infections, and some chronic disease such as hypertension and COPD. Patient expectations were also simple and predictable: to be patched up with something cheap and returned as quickly as possible to their normal daily routine. The biggest challenges usually related to convincing patients to drive the 60 minutes to the nearest hospital for lab or x-ray testing. Even with the limited skills and experience of an industrious fourth year student, I was able to function credibly in this environment.

Once or twice a week, which was often enough to keep us on our toes, we came across a patient or problem that was different. I particularly remember the sheep farmer and his skin lesions. I was staffing the clinic on my own that afternoon, with my physician back-up a phone call and 10 minute drive away. (Alone is not truly accurate, as I was supported by our nurse and receptionist, two wise women born and raised locally and worth their weight in gold for their knowledge of the community, and the basics of common sense medical care.) I was enjoying the heady mix, the rush of being trusted to function as a real doctor suffused with the all-to-justified fear of screwing up.

Grant came in near the end of the afternoon, apparently having rushed his afternoon chores and definitely without washing up or changing clothes, in his desire to get there before we closed. Clare came back to the small office where I was reading about a previous patient’s problem and handed me the clipboard with the form for his office note. “You’ve got something interesting in the exam room,” she said. I reviewed the single page chart and learned that Grant was 58, married, living south of town on a sheep farm, uninsured, a smoker, was on no medications and had no allergies.

I entered the room, introduced myself as Peter Elias, a medical extern helping Dr. Kay in the clinic, and asked what brought him by today. “I’ve got anthrax. My uncle’s liniment don’t work. I need antibiotics.” He showed me several black and crusted lesions on his forearms, ranging from 1 to 3 centimeters across. I’d never seen anything even remotely like this, but my first impression was some kind of localized burns. I was sure it couldn’t be anthrax, though. It wasn’t on my list of the 100 commonest skin conditions. I told him anthrax was the same as plague, a serious respiratory illness, and suggested that I scrape some of the crust off his sores to examine under the microscope so we could send the scrapings off for culture. He shook his head and told me he couldn’t pay for fancy testing, and besides, that takes too long. Undeterred, and not listening well, I explained that if we sent the specimen over today, the hospital lab should be able to call us a culture report in two days, three at the most, and that wound cultures were pretty cheap. Setting his jaw and looking right at me, he said it would take three weeks to get the report back and cost a couple hundred dollars. All he wanted was his prescription, but if I wouldn’t give it to him, he’d maybe just use the stuff they give sheep for anthrax.

“Wait here,” I said (still not listening well), “I’ll be right back. I want to show you something.” I went back to the little consultation room where the clinic textbooks were kept, pulled the big dermatology book from the shelf, and headed back to his exam room as I scanned the index to find anthrax. “Here,” I said, leafing to the pages about cutaneous anthrax and laying it open on the exam table. And there, in living color, were three photos of lesions identical to those on his forearm. 

 

“Yup. That’s just like what I got from my sheep, same as three years ago. Cleared up fine with antibiotics. My sheep got it again, probably ‘cause I can’t afford to treat the pasture like they told me to.”

He got his antibiotics and I got important lessons in listening and humility.

 


 

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