Healthy Skepticism

I was one of those kids who believed everything.  Pretty much every rumor, myth, and urban legend that came along sucked me in like a dust ball at the mercy of a Hoover vaccuum.  In grade school, one particularly unenlightened teacher taught us that the force of gravity relies on the spinning motion of the earth and that if the earth were to ever stop rotating we’d all float away.  That night I prayed more forcefully than usual—please, God, don’t let the earth stop spinning!  I remember freaking out a bit when someone told me that Led Zeppelin’s Stairway to Heaven contained coded messages when played in reverse—slow dances in junior high were never the same after that.  When I read my first Michael Crichton book (Andromeda Strain) I read the references in the appendix and believed for a time that this fictional account of germs from outer space had actually taken place.  In high school I attended a show put on by a hypnotist and believed that the participants pulled from the audience were actually at the mercy of the mesmerist’s bewitching commands.  I caught “The Omen” on TV late one night and was sure the world was coming to an end when I realized that the “666” citation was an actual passage in the Bible.

It’s a good thing I wasn’t alive at the time of Orson Welle’s ill-fated War of the Worlds broadcast in 1938—I’m sure I would have packed my bags and headed for the hills.

My naïveté stuck with me into my medical school training.  I was working in the ER during one of my earliest rotations when a young man came in with a bullet hole in his foot.  I asked him what happened as I cleaned the wound.  “There I was, minding my own business, when some dude came up and shot me in the foot.”  (Note: My youngest brother, currently a medicine resident, maintains that the most dangerous thing you can do is to “mind your own business” or be anywhere near “some dude,” since this is most sure way to end up in the ER.)  I was a little shocked that there are people out there that would walk up and shoot you in the foot for no good reason—what kind of crazy world is this?!

A little later a police officer strolled into the ER.  He took one look at the gunshot victim and, without hearing the patient story or examining the facts of the case, demanded to see the kid’s pants.  My patient initially demurred but finally reached under the examining table to produce his trousers.  The cop reached into the right front pocket, pulled it inside out, and showed us the burn mark and the bullet hole.  It took this police officer about three-tenths of a second to correctly reach the conclusion that the kid had shot himself in the foot with his own pistol.

I learned a valuable lesson that day: don’t believe everything you hear, especially from patients.  My experience as a doctor over the last two decades has changed me from a naïve believer to a hardened skeptic.

Why would a patient not tell the truth?  To be sure, there are some individuals—like the young man with the hole in his foot—who are consciously trying to hide evidence of their own self-destructive mischief.  The most common situation where we see this is when we ask people about their alcohol consumption.  There is a widely held axiom that the number of drinks per day that a patient admits to needs to be doubled in order to be accurate.  “I have only a couple of beers a night” translates to about a 6-pack a day.  The urine drug screen in the ER tends to be a more honest source of information than the stuperous patient himself.

Most patients, however, are not out to purposely mislead in order to hide misdeeds or bad behavior.  Indeed, most patients who misdirect are doing so in an attempt to make their case more understandable for the treating doctor.  A good example is a man I recently evaluated for chest pain.  He told me that his discomfort had started that morning and that it felt like “an elephant sitting on my chest.”  As I pressed him further I learned that his symptoms had been present for weeks and were considerably less dramatic that the pachyderm story implied.  It turns out he had already sought care from his primary doctor and from another ER for the same problem but had not received what he felt was a satisfactory evaluation.  For me he dramatized his symptoms based on what he thought I needed to hear in order to get me to give his heart a thorough assessment.

At the other end of the spectrum is the patient who downplays his symptoms.  The typical story is the man who sits in the ER bed and tells me that he’s had the same pain everyday for a couple weeks and that he’s convinced it’s just his stomach acting up.  When I hear a story like this I generally follow by trying to pin down why, after several weeks of symptoms, he decided on that particular day that things had gotten bad enough to make him want to come to the ER.  At this, the truth generally comes out and is most often related to some permutation of “my wife/girlfriend/mother made me come in.”  I then stop and turn to the more responsible member of the family and continue my questioning, with much better results.

The funny thing with patients like these is that even the most tight-lipped become loquacious about their symptoms once we have confirmed the diagnosis of coronary disease.  Once the 99% blockage has been identified and repaired the story seems to change quickly: “Doc, you wouldn’t believe the chest pain I was having.  It was murder.  Brought me to my knees.  I knew something BAD was wrong.”  Sure.

I’ve managed to evolve from a naïve believer to a hardened skeptic, all thanks to medicine.  I’ve learned to question just about everything I hear and demand to see the data on anything that sounds remotely suspicious.  Disbelief is my knee-jerk reaction to any news of a stunning medical discovery (“tap water causes cancer!” “mega-vitamins cure coronary disease!”).  Even theories derived from respectable research don’t change my pattern of practice until the findings are propped up by a series of confirmatory studies (as examples see recent blogs on Multaq and Niaspan).

That said, I don’t overtly disbelieve everything patients tell me—I just recognize that it’s human nature to adapt our narrative to the perceived situation or to target some concern.  Another example: This week a patient told me that he experiences palpitations whenever he takes a particular medication his doctor recently started.  I had no reason to doubt the truth of what he told me, but further probing revealed additional information.  The symptoms, it turns out, come at other times as well and started several weeks before the new drug was prescribed.  The man had crafted his less-than-forthright story in an attempt to address his own concern about the safety of the new pill.

I’ve read articles in health magazines that admonish patients to be open and honest with their doctors.  This is indeed good advice but ignores the reality that all of us obfuscate to some degree when detailing our symptoms, usually not out of a desire to mislead but because our own concerns, beliefs, and opinions cast bias on our narrative.  I suppose my only guidance on the subject would be to recognize that most doctors tend to harbor the same degree of skepticism that I do and to not be upset when they press you further anytime the story doesn’t fit quite right.  It’s kind of like the TV detective who asks a witness for more information, even if it doesn’t seem relevant to the case—“tell me everything and I’ll decide if it’s relevant,” he says.

My level of skepticism tends to annoy some of my family and friends, but I think it’s healthy in my line of work.  The best part, though, is that I no longer fall for every urban myth that comes my way.  I can listen to Led Zeppelin without a chill up my spine, I don’t lose sleep over earth’s gravitational field, and I no longer worry about waking up in a strange bathtub filled with ice and missing a kidney.