“Good morning sir. What can I do for you today?”,
I say, trying to smile warmly. Because it is definitely not this man’s fault that I was rear ended by a commercial bus this morning on my way to work, which led to a heated argument with the driver and 14 passengers. And I have since been wondering where to find the astronomical fee announced with glee by the auto mechanic, after assessing the damage to the car…
“Doctor, I have an astrocytoma!”
As my brain tried to juggle which of the classes in medical school, I last heard that word decades ago, I took a deep breath, reminding myself that Hippocrates must have had such moments. So, I tried again.
“I’m sorry? An astrocytoma? How do you know this?”
I infused some friendliness into my tone, in a bid not to downplay the seriousness of the encounter, at the same time, scanning him for a mental disorder.
“Well, for the past 2 months, I’ve been having this recurrent frontal headache – worse in the mornings, aggravated when I cough and temporarily relieved with Paracetamol. I also have blurred vision and I have been sleeping less than usual. I don’t have diplopia or projectile vomiting and I know I don’t live in a Scandinavian country, but I travelled to Sweden a couple of years ago. What else could it be? I’m not thinking too much, and I treated malaria and typhoid last month. So, I want to do an MRI”.
If I may digress a bit – in my years of practice as a Family Physician, I’ve always had the opinion that non-medical stuff such as psychological profiling of patients, financial literacy and information and communication technology should be taught in medical school as foundational courses.
The process of balancing one’s psyche prior to and during each patient-doctor encounter as a generalist, to be mentally prepared to hear all sorts of complaints and address each on merit as they come, is a very important skill. Even more importantly in a country like Nigeria – where I practice – that is rich in cultural and spiritual causes of diseases and a dearth in healthcare resources and research.
In this clime, where stress and frustration show no social selectivity, it becomes a psychological battle of wills between the doctor and patient. While the “I need a solution to my problem”-driven patient has a genuine, (albeit fantastical) complaint, the physically and mentally exhausted doctor has a readymade “I honestly don’t have time for this” response and diagnosis. However, this causes both parties to eventually leave the consultation dissatisfied. With doubts over the patient’s sanity on the one hand, and of the doctor’s professional qualification on the other, being pin ponged back and forth.
The GOOGLE PATIENT is the one who looks up their health concerns or complaints on the internet and comes to the clinic, armed with their “Internet Generated Diagnosis” (IGD), for a medical consult. The process is familiar – they go on Google, key in health symptoms, click “enter”, and … Voila! A long list of probable, near frightening, unpronounceable diagnoses pops unto the screen. Then, depending on the patient’s anxiety and literacy level, he or she can then pick the disease entity(s) that best suits the particular set of symptoms they exhibit. Armed with this pseudo-knowledge and “IGDs”, they begin to “doctor-shop”- hopping from one doctor to another – seeking validation for their findings. With repeated visits, they lay siege upon clinics, picking apart the bewildered doctor’s knowledge, patience and last nerve.
With expert collaborative cunning, most of these invalidated “internet hospitals” know exactly how to lure and capture the minds of the “uninformed” into their web. Other virtual “medical” pirates scavenge these sites, advertising, promoting and promising treatment modalities of all ramifications for these mysterious ailments. The patient – hungry for more and fuelled with this new realization – scours more sites until they hit the mother lode, a most ‘suitable’ diagnosis. And the vicious cycle is born.
“Sweden, you say? Very interesting”, I nod in agreement.
“Well sir, I fully understand your concerns. However, why don’t you tell me a bit more about your symptoms, and let’s work our way up from there?”
I automatically, but carefully acknowledge his concerns as genuine and proceed to inform him of some other more likely, (and less frightening) diagnoses whose investigations cost much less and are more epidemiologically tuned to this part of the hemisphere. I lace my arguments with suggestions – starting a journey with baby steps instead of a leap, and not wanting him exposed to radioactive waves “just yet”. He readily agrees and relaxes. I then proceed to enquire about his past medical history including medications he has tried, his social and family histories.
Some moments later, the patient leaves the consulting room satisfied with having “learnt something”. He is sent for “simpler” laboratory tests, given a prescription for mild anxiolytics, a referral to the ophthalmologist, some counselling on lifestyle modification strategies including relaxation techniques to try and a feedback assignment. He returned two weeks later, feeling and sleeping remarkably better, headache gone and wearing smart pair of spectacles with blurred vision cleared. All talk of astrocytoma and MRI magically “gone with the wind”.
I advise patients not to visit the internet with their complaints until after a visit with their doctors. They may then Google details of what the doctor (or medications) proffer. They should be encouraged to write down their findings and questions against their next appointment. That way, they understand, have a major say, and are better compliant with their management plan.
Doctors would do well to first identify these patients, towards incorporating tools such as cultural competence and good communication skills. We should show empathy, try to patiently hear them out and acknowledge their concerns – no matter how weird or far-fetched they may sound. We should then – following the principles of best practice – suggest alternative, simpler, evidence-based diagnoses and encourage them to write down or record their complaints AS THEY FEEL THEM, and not as guided by the internet.
Follow-up visits, (which might end up swinging in the favour of the patient’s “IGD”, after reviews and investigations) should follow the same pattern. As we confirm our diagnoses, tactically admit to errors in judgment, or have to break the news about a bad or poor prognosis of their ailment.
When dealing with a “Google patient” in the consulting room; sparing those extra minutes, having a keen mind and a drawer-full of ‘last nerves’ is a good idea. For this is no easy feat – even for Hippocrates!
Dr Almaz Brown (MBBCh, MPH, FWACP) is a Consultant Family Physician with about 2 decades of experience in practice. She writes from Federal Medical Center, Ebute-Metta, Lagos in Nigeria.