Since When? Looking for Change: The Heart of the Art of Diagnosis

Our receptionist asked: “Do you want your 10 o’clock to reschedule? He has a runny nose, a cough and muscle aches”. He failed some of the Covid screening questions.

“Well, he has allergies, chronic bronchitis and fibromyalgia. If he’s worse than usual, reschedule, but if he’s the same as always, I’ll see him”, I answered.

Mr. Swift’s wife told me he has diarrhea ten minutes after every meal, sometimes even fecal incontinence. When I asked how long that had been going on, she said two years, ever since his colon resection. And yes, the surgeons knew about it. The Swifts just never mentioned it to me.

“How long have you had these headaches?” I asked Randy Blake. “A while”, he answered. “Ballpark? A week, a month, a year?” I asked. “Maybe two or three years” was his reassuring answer. Not that it couldn’t be something serious, but it certainly wasn’t a fast moving disease.

It is striking, how often I as a physician am presented with a symptom without any information about its duration, speed of onset or progression. But that, the time factor, is usually the most important part of a case history.

(From a SlideShare presentation I created several years ago)

Our bodies tend to be in a fairly steady state: Our weight, energy level, appetite, elimination habits and even our mood tend to vary only within a certain range. The more things deviate from that typical range and the faster this occurs, the more aggressively we tend to pursue an explanation.

A typical example of this is the kind of patient who comes in for a routine visit, 15-30 minutes at most, and mentions more than half a dozen symptoms just to be sure they’re not serious. One patient I had even said “just so it’s in my record”. Taken the wrong (?) way, that could even be seen as building a case against me in case one of those symptoms later turned out to be something serious that I overlooked.

Think of this as one of those sets of near-identical pictures where you have to spot the difference. That’s usually an easier task than finding something wrong with one single picture; our brains are wired to compare, and that’s easier with a real set of pictures than one faulty picture we have to compare with our internal vision of what things should look like.

Also think of this as considering the inevitability of age related changes. If someone seems to age more rapidly than we are used to, look for disease. Graying hair in a middle aged person is expected, but in a twenty year old it is very unusual. (That, by the way, is how I explain osteoporosis, T-score and Z-score to my patients.)

Timing is everything.