Physician, Know Thy Patient

Even before I examined her painful left knee, the patient in Examining Room 8 asked if I thought she needed an X-ray or an MRI and if I would prescribe one of the new arthritis medicines that she knew about from TV.

Such requests are all too often the prelude to bad medicine -- needless procedures and needless prescriptions or sometimes even an irretrievable contest of wills. But this patient and I knew each other too well for such an outcome.

I’ll call her Mrs. Martin. I had taken care of a relative of hers about 15 years earlier, when he was dying of cancer. I remember one house call in particular, when I sat at the kitchen table with the family as the members acknowledged that he wasn’t going to get better, and it was time to stop the chemotherapy. The focus of his care, they decided, should be shifted to keeping him as comfortable as possible.

Mrs. Martin had been my patient since then. She suffered from chronic anxiety and panic attacks. Over the years, I had tried to help her identify the source of her anxiety but never made much progress. I prescribed several different medications, though none provided enough relief to make the side effects worth putting up with. And I referred her for counseling, but that didn’t help either.

Mrs. Martin discovered that the best way to control her anxiety was to walk five miles almost every day. And this she had done faithfully for about 10 years. Unfortunately, her knees apparently had not been designed to withstand this much use, and she was, at this visit, most likely suffering from a flare-up of osteoarthritis, or “wear and tear” arthritis.

One of the tragedies of American medicine is that primary-care relationships like the one that Mrs. Martin and I shared are becoming quaint relics of the past.

Most of the knowledge that now guides medical care comes from studies sponsored by drug and medical-device companies. And through advertising and news media, patients are introduced to these companies’ products as well. The information is designed to persuade us that good care calls for increased use of the products, sometimes without documented benefits to patients. (There are as many MRI scanners in Massachusetts as there are in all of Canada. But there is no proof that the residents of Massachusetts are any better off for it.)

Mrs. Martin knew me well enough to trust me; I knew her well enough to know that the best diagnostic test in her case was a two-week trial of swimming (instead of walking) and taking inexpensive over-the-counter anti-inflammatory pills twice a day. Her pain improved, and we were soon talking about other ways she could exercise without overworking her knees.

One hundred years ago, the first professor at the Johns Hopkins medical school and greatest clinician of his time, Dr. William Osler, said that “it is much more important to know what sort of patient has a disease than what sort of disease a patient has.” In most cases, that remains true today, though Osler’s wisdom is almost completely drowned out by the commercial din that now dominates American medicine.