drmargaret

“When hearing the thundering of hooves, look first for horses not for zebras” is an old adage of medicine. The saying advises doctors to first look for the common place before looking for the unusual. Unfortunately some doctors never suspect the unusual and for those of us with “zebra” medical conditions we remain undiagnosed or limited in treatment options for a long time.

When I first ventured into private practice I decided I needed to support myself and wanted to work with a large group of people. Most psychologists build their practices slowly over a period of time. It’s a safer route to take. I had been quite ill my last years of post doctoral study and didn’t want to work in the sex offender field. So I needed income and bounded into private practice with a business plan to get patients quickly. I was hunting for zebras. I went to several internists and primary care doctor in the area and a few family practice doctors and told them that I wanted the people they really didn’t want to see. These were the patients that weren’t getting better. The doctor may not know what was wrong with them. The doctor may have thought it was all in their mind or that the patient just wasn’t doing what the doctor wanted with treatment. I wanted people who were complaining about being sick for at least six weeks and preferably six months. I got an entire case load within three months.

Medical psychology was an almost unheard of field at the time I started practice. The first thing I did was to take a history. History taking takes time. Mine took an hour and a half on average. I drew diagrams of geneology. I listed symptoms in detail. I had people bring in bottles of every single bottle of medication they were currently taking, even the over-the counter things. I detailed out what the person told me about what was happening. Men and women talk about their symptoms differently. Men and women take medications differently. Men and women complain differently. I listened and wrote things down. In some cases, I could figure out what was going on and what was wrong with the person. I could call the MD and tell them or write a letter. In other cases I could get the patient to tell the doctor what their symptoms were using different words so the doctor would understand. In other cases I could explain to the person how the medications had to be taken and how the medications worked on the disease so the person would take them correctly.

Other cases were more complex. Some people can’t tell what they are doing when they get pain because all they notice is that they hurt. So it’s important to teach them how to keep track of pain. I helped people learn to do research on their symptoms. They learned to record, and track and grade intensity and frequency and what was going on at the time of the onset of the pain. After awhile they could see some patterns. In other cases they could experiment with different treatments. New treatments come out all the time. People think some treatments work but it’s important to look at data to see if they work or not. I taught people how to collect data.

In cases where there was no diagnosis it was important to look at a constellation of symptoms. It’s important to understand the medical decision trees that doctors use to diagnose. Lots of time it’s hard to tell what’s going on when someone has been in a lot of treatment. To get a clear picture a new doctor might stop all the treatment by tapering off and discontinuing all the treatment to get a fresh look at the case without treatment. The new doctor will order all new labs to be drawn up at that point. Laboratory studies and observation and examination form the backbone of how physicians make diagnosis. Responses to medication and treatment are next in the diagnostic process. The last part is confirmation of improvement or worsening by the patient. Patients often get frustrated and often feel disregarded by the process. Medical doctors feel that patients interfere with diagnosis and treatment and don’t follow directions.

Psychologists make diagnosis differently from medical doctors. Psychologists start off by making a series of hypotheses and getting patients involved directly in the treatment process. Medical and legal psychologists collect more data than most clinical psychologists doing general treatment do. Medical psychologists focus on medical situations. Legal psychologists deal with any aspect of law and psychology. Another name for legal psychologists are forensic psychologists. Psychological testing is used by clinical and legal psychologists and may be used by other types of psychologists as well. I used it occasionally as a medical psychologist to give a patient an idea about how well they might do with a specific type of medical procedure like an elective surgery. Testing was also used to see if people were depressed or anxious following medical illnesses like cancer or heart operations to make treatment decisions.

Psychological testing is often used in clinical trials with orphan drug testing specifically designed for people with rare medical conditions (zebras). This allows the drug company to know who might benefit the most from the drug and have the least side-effects.

Now that there’s a television show highlighting rare infectious diseases (House), more interest is being paid to unusual disease presentations. Few doctors will ever see the cases Dr. House or his team sees. I lament that a psychologist isn’t part of the show or that good history taking isn’t shown. Detective work and medical investigation into homes for possible causes of infection are shown and are hardly routine. They do show some of the genotyping and genograms episodically and they do show the medical decision trees and the countless hours of computer or library research needed into the cases. Most large cities have a medical center that has access to a medical library. It’s important when using the internet to look for articles that are from journals that are peer-reviewed and have good medical acceptance. There are a lot of articles that have no scientific basis to them.

There are a couple of very basic books I recommend for people learning how to communicate with their doctor about their symptoms:

The Merck Manual-this book lists medical conditions and symptoms, common tests, and prognosis. It is updated every few years. It contains normal laboratory chemistry values. It requires a medical dictionary to understand some of the terminology. If you are a person who gets every disease you read about, then don’t read this.

The Physician’s Desk Reference-this book is a compilation of all those inserts you get with all the prescription bottles from the manufacturers. It has pictures of the pills or capsules or ampules of common medications. It lists the side effects and common dosages. It lists some interactions. There is also a version for herbs and over the counter medications and supplements.

Gray’s Anatomy-this book contains pictures and line drawings of body parts. If you don’t know what something is or where it’s located, this tells you and shows you a drawing in cross section. There is also a coloring book version.

I have no financial interest in any of these publications.