Seeing the Big Picture in a Clinical Situation

Last night’s post was about focus, which is often a very good thing. But I have come to think that physicians under pressure can have a tendency to hyperfocus. When that happens, the physician needs a team scanning the area and events beyond the physician’s own field of view. And if nobody does that, chaos ensues and bad things happen. I’ll come back to that in my next post.

But right now I want to talk about a Big Picture that we clinicians ourselves need to recognize - the overarching disease process, etiology, roadblock or symbolic significance behind an individual patient’s symptoms, improvement or worsening.

Medically speaking, the Big Picture in a patient’s clinical situation could be something that seems small to an “objective” observer. But the way I think of this is that we need to look at the different small nuggets of clinical clues each patient gives us and then step back far enough in our minds to imagine them together and then to imagine how they relate to each other.

We must not lock on too quickly to the most common or the most dangerous symptom or differential diagnosis we come up with, but ask ourselves if all or some of them might be interconnected and representing an even Bigger Picture than the one we first imagined.

Of course, the better you know your patient, the more likely you are to make these connections. And, even though a few patients I have known for years in my previous practice have followed me to Galileo, I am seeing a lot of new patients, but one hour initial housecalls give me a better jumpstart than my former 30 minute new patient clinic visits with all their built-in distractions and procedural delays.

The types of things I think about with big picture are family history items, perhaps beyond first degree relatives.

If somebody’s uncle had similar symptoms and died when they were one year older than my patient is now, I need to keep that in mind, at least because of the symbolic significance of such symptoms.

As I wrote recently, a mother with migraine headaches may have a child with abdominal migraines, which at first glance may seem like different problems if you focus too quickly on the symptom location.

I also think of how people with one autoimmune diagnosis may harbor others that haven’t been identified yet.

And I think it is important to let patients prioritize for themselves as much as possible. In the big scheme of things, agreeing to work on the patient’s highest priority items makes you more likely to later on bring them on board with other things they haven’t thought of as important before. Their blood sugar may be more abnormal than their blood pressure or cholesterol, but the big picture involves all of them, so why try to micromanage the order of things? The big picture involves all of them.