Symptoms of Unknown Origin: A Medical Odyssey

Chapter 13. The Diarrhea of Agnes

102 13 The Diarrhea of Agnes Agnes was referred to me by a physician from the next county. I had returned to Vanderbilt and Saint Thomas from my sabbatical in Fairhope, even more determined to explore and define the problems of patients with SUO. Agnes had suffered from chronic diarrhea for nearly a year. An extensive GI workup by her referring physician, including a small-bowel biopsy, was entirely normal. All symptomatic medicines had failed to produce any consistent relief. Every test I might consider had already been done, with negative findings. The results of the workup ruled out a long list of diseases, but it did not establish a diagnosis. Agnes had noted no pattern to the diarrhea and thought it came “all the time.” I had discovered through the years that almost no symptom comes “all the time.” I had learned to gently challenge that statement by saying, “By ‘all the time,’ I am wondering if you mean every minute of every day and every night?” Note how I embedded the challenge in a question. Embedding challenges in questions reduces the chance of a defensive answer. People hear embedded challenges as less confrontational than direct challenges. Agnes’s answer was quick. “Well, no. Not all the time. It comes and goes.” There had to be a pattern of some sort. All symptoms wobble, vary, and come and go. The trick is to get the patient to find and define that wobble, that variance. Insistence by a patient that Meador฀pagesFeb15.indd฀฀฀102 2/17/05฀฀฀5:35:09฀PM The Diarrhea of Agnes 103 any chronic symptom is continuous or “all the time” is a red flag. By challenging Agnes, I was setting in motion a search for the pattern of the diarrhea. She did not know her pattern of diarrhea on the early visits and would have to discover it. I had found my approach of refusing to label patients prematurely more and more useful and productive. I said to Agnes, as Sapira taught me, “I don’t know what you have . . . yet.” Again, I emphasized the “yet.” I also continued to list for patients many of the diseases I knew were absent. I was careful to name those diseases that had killed some member of the family if I was sure the patient did not have that disease. My reasoning was that whatever buried anxiety patients might have had over the family “killer” might be reduced by specifically telling them the disease was not present. In some cases, I suspected that the anxiety and worry over inheriting a family disease were sufficient in themselves to produce the symptoms . My statement at least got the subject out in the open in a subtle manner. For Agnes, there were no family killers of note. Both parents were still alive and all grandparents lived into old age. With Agnes, as with other patients, I wanted to avoid using what I call “dead-end diagnoses.” Such labels inhibit all etiological thinking by the physician and the patient. In a case like Agnes’s, examples of dead-end diagnoses are spastic colon, irritable bowel, and sometimes diverticulosis. Without exhaustive examinations for causes, these labels are prematurely definitive. Something, usually something ingested, is causing the bowel to be irritable or the colon to be spastic. Why not try to identify it? That was the direction of my thinking with Agnes. I came to my two favorite questions. I asked Agnes: “What are you doing that you should stop doing? Or what should you be doing that you are not doing?” With more and more experience with patients, I was becoming extremely careful in my choice of words. Notice that both questions leave out all specific detail. There was no mention of time or Meador฀pagesFeb15.indd฀฀฀103 2/17/05฀฀฀5:35:10฀PM 104 Symptoms of Unknown Origin place or context, yet both questions clearly directed the patient to do an exhaustive mental search. The command was embedded in the unspecified language. I was directing the patient to search for an answer, but I was not specifying in any way what area of life was to be scanned. In the first question, I left open all possibilities for what actions the patient could stop doing. In the second question , I left open all possibilities for what actions should be added to...