"Good morning, what seems to be the trouble lately?": what should happen when seeing a doctor

You may be surprised to know that despite all the hoo-ha about blood tests, MRI, X-Ray and many other complicated medical investigation gimmick, the most important and useful tool for a doctor in making a correct diagnosis is his pair of hands, and his mouth.

Mouth to ask the right questions, and hands to touch and feel the right places. Therefore, your visit to the doctor's clinic is the first and most important step in getting a good treatment to your problem.

Here's a list of the things that should happen (according to a student doctor's textbook) ; compare this with your real-life clinic experience.

1) The moment you stepped in, the doctor's eyes should be all over you. Observing your facial expression and appearance, the way you walk, to see if you are limping or in pain. Also as a gesture of welcoming you.
Hmm…: Benarkah? One famous cardiologist in Ipoh was typing happily with his eyes on the screen when I brought my late grandfather in.

2) Then the doctor should introduce himself, and shake your hand, and address you accordingly(your name and title). Then, he should ask, "What has been the trouble recently?" or "When were you last quite well?"
Hmm… : Except for junior doctors or one freshly back from a British hospital, the doctor is highly unlikely to engage in such a British manner. Gosh, I myself would not ask a question like that. Maybe a more common way of asking would be: "Hello auntie/uncle….What's the matter?" or worse, "Yes, apa sakit?". Or if you encounter one like that Ipoh cardiologist, he would continue typing some dunno-whats into his PC while waiting for you to open your mouth.

3) The conversation between you and the doctor should be a natural, smooth one. There should be no element of interrogation by the doctor's tone and words. He should be conversational, asking general and specific questions interchangeably. In short, you should be made relaxed, and comfortable. You should not be shy to ask any questions. After all, you are paying.
Hmm… : Surely there are many doctors who practice this style, unless you are unlucky to meet one like that Ipoh cardiologist.

4) What should the doctor ask? Many things. This Q&A session should be fruitful for both you and the doctor. For the doctor, your history of the illness, and social and past medical history is indispensable to a proper diagnosis-making. Type of questions:-

i) About your current problem/presenting complaint: you should answer according to how exactly you feel. Try your best to recall correctly when did it start, the duration of the pain/problem, the character of the pain/problem, about your last meal, your travel history, etc. ii) About your medication and allergies:- Are you taking any drugs currently? What about traditional herbs and tablets? Any drugs that make you miserably and itchy?
iii) Your past medical history:- your previous hospital stay, types of surgery, are you diabetic, asthmatic, hypertensive(high blood pressure), HIV positive, stroke, epileptic, etc. This is very, very important. Do not lie to the doctor, or hide any important information from the doctor. A genuine, ethical doctor would keep everything you tell confidential, and would not use against you.
iv) Your social history: - your marital status, your family tree, your sexual activity, your occupation, your travel history, your hobbies, your habits, your financial sources, etc. Trivial it may seem, but it may have some vital clues that help the doctor.

For you, this interview should be useful for you to clarify any doubts and alleviate any unnecessary fear. Be relaxed. Your anxiety may confuse blood pressure and pulse reading.

Hmm… : This is the ideal situation for the doctor-patient interview. What really transpire is up to the time available, the doctor's enthusiasm and methods, and also your co-operation. This is why a good, classic example of a doctor visit should last for at least 20 minutes. However, the heavy patient load in the local setting normally does not allow such luxury.

5) Next, the doctor would perform a physical examination on you. Bluntly said, he would touch you. He may even have to ask you to undress. All this should be done in a professional, clinical manner. You should give full trust to the doctor and his character.
Normally, the doctor would pay specific attention to the area(system) of the body thought to be most probably the problem, after obtaining clues from the interview. However, a proper, thorough examination should include all systems. This can be time-consuming, and a waste of precious time, especially in an emergency. Nevertheless, a doctor must not fail to appreciate the general signs and appearance.

6) What will the doctor do? The doctor will do the following: looking(inspection), feeling(palpation), tapping(percussion), and listening(auscultation), using primarily his eyes, fingers, palm and the stethoscope. He would also do some measuring like your blood pressure, weight, height, heart and breathing rate. Your body is hidden with clues.
Example:
A. a yellow discolouration of your sclerae and skin would mean you are jaundiced, which mean you most probably have problem down there in your liver, or gall bladder.
B. A bluish discoloration of your tongue, skin would mean that you are cyanotic - lack of oxygen in your blood. A pale appearance would mean that you are anaemic - you lack haemoglobin in your blood.
C. The amount of hair or the lack of it location of fat deposition in your body, your skin can tell if you have a hormonal problem.
D. Swollen(oedematous) hands and feet, or face may mean a broad range of problems(kidney, heart, circulation, nutrition, infection).
E. Any nodular swellings in your groin, your neck, your armpit may mean an infection. Lumps and enlargements may indicate tumour growth.
F. The feel and character of your nails, fingers and palm is a good indicator of a number of conditions.

7) There can be a conflict between the need for a thorough inspection and the need for modesty. For certain parts to be accessible like the inner thigh, genitals, and breasts require the patient to undress. These parts can be covered temporarily while other parts are being examined. If the doctor is a male, a chaperon must be present.

Hmm… : I recall there was a story in the newspaper about a woman who claims she was sexually mishandled by a doctor who obviously did a very thorough examination on her, although she merely complained of stomach discomfort. Now, from a clinical point of view, the doctor did nothing wrong because it is justifiable, at least theoretically, to examine thoroughly so that he would not miss any clues, which can be harmful if missed. What transpired after that news, we do not know. Nevertheless, females should ensure the presence of a chaperon when examined by a male doctor.

Conclusion
Diagnosis has been defined as 'the crucial process that labels patients and classifies their illnesses, that identifies (and sometimes seals) their likely fates or prognoses and that propels us towards specific treatments in the confidence that they will do more good than harm.* Therefore, you should ensure that you have co-operated well with the doctor, and aided him in making THE diagnosis by giving the correct answers and vital information, and also by trusting him.

Reference
i. Talley NJ, O'Connor S. Clinical Examination: A Systematic Guide to Physical Diagnosis. 4th Ed. Singapore: Apac Publishers, 2001.

ii. Longmore M, Wilkinson I, Torok E. Oxford Handbook of Clinical Medicine. 5th Ed. New York: Oxford University Press, 2001.

* Sackett DL, Haynes RB, Tugwell P. Clinical epidemiology. A basic science for clinical medicine. Boston: Little, Brown & Co, 1985.


Klinik Ikanbakar 01 2:00 PM 9/18/03