So much for snap judgments about patients

This doctor's mistaken assumptions taught him the danger of stereotyping.

By Richard L. Fleming, MD
Internist/Vallejo, CA

There's something to be said for 20 years of practice. Like many doctors with such lengthy tenure, I feel I can size up new patients quickly and accurately.

Not that I'm never stumped, mind you. But over time we doctors develop such gut-level instincts that within minutes after encountering new patients we generally know quite a bit about them.

One common enemy of good medical practice, however, is stereotyping, a mistake I made a few years ago. When I looked at the schedule for my next appointment that day, it was for a 38-year-old patient whom I'd never seen before. (I'll call him Oscar Robinson.) The medical assistant had recorded his chief complaint as "Back pain. Wants Rx." My hackles rose a bit as I took a last sip of coffee before going in to practice medicine on Mr. Robinson. "Probably wants his codeine," I thought as I left the sanctuary of my office.

In the exam room I found an enormous man, easily 6-foot-5, and nearly 300 pounds of muscle, trying to perch on the exam table. He scowled, and grunted "Hello" when I stuck out my hand.

"My back hurts!" he said with authority, leaving little room for doubt. He was clearly proclaiming his diagnosis, and setting the stage for the therapy he would soon demand. I'd been in these situations before, and I could already tell that he would go on to explain that ibuprofen doesn't work, and that he'd need something stronger.

"Okay," I said, "but I need to get a little more history, and examine you so we can find out what's causing your pain before we decide on the best therapy."

"You can forget that. I already know why my back hurts."

Right, I thought, anticipating having to report him to our medical center's drug abuse hotline.

"So tell me why your back hurts."

"Gunshot wound."

"Gunshot wound?"

"That's what I said. I got shot in the back three years ago, and it still hurts, especially if I have to do heavy lifting. And I have to do a lot of that on my job. That's why my back hurts."

Great, I told myself. Not only will I have to decide whether to accommodate Mr. Robinson's request for narcotics, but he's probably going to want a sick slip and is angling for disability.

"How did you get shot?" I asked.

"Folsom State Prison. The guards set up a fight in the exercise yard between the whites and the blacks so they could shoot people. I got caught in the middle. I wasn't involved, but I got shot anyway."

Well, I thought, this certainly wasn't your usual back pain. I figured it wouldn't be difficult to find out whether Robinson was telling the truth, so I began my exam. He readily showed me the wound scar, a sizable dent over his right lumbar area. Okay, so he had scar tissue there that could have come from a gunshot.

I then asked him, "Where do you work?"

"The Oakland Zoo. We're building a fancy new pen for the lions. The managers say it'll fool them. It'll look so much like Africa they won't know they're in the zoo. Hell, those managers don't know what they're talking about. Those lions will still know they're in the zoo. Trust me, I know. I've been there."

Now I was getting intrigued, and actually warming a bit to Mr. Robinson. It's not often one hears a story like this. An ex-prisoner, shot by his keepers, is helping build a prison for the lions, but with no illusions. Though he now works for the zookeepers, his sympathies are clearly with the lions.

After a somewhat cursory exam, I asked, "So, I suppose you want some codeine?"

"No way!" said Robinson. "I wouldn't touch that stuff. I just want my ibuprofen. It works good for me. And Doc, could you make it the 800 milligram? I'm kind of a big guy." (He could have gotten ibuprofen over-the-counter, but it was much cheaper under his health plan's modest copayment.)

"Do you need a work slip?"

"No, I can work through the pain. Besides, I like my job, and I like watching the lions. I'm heading over there to work this afternoon."

In 15 minutes I was back in my office, having learned another lesson about practicing medicine. Health care professionals should not prejudge new patients. We must take them as they come, and evaluate them as individuals. We never know what's behind the next exam room door. I guess that's why it's called the practice of medicine, from our first day as physicians to our last.

 

Richard Fleming. So much for snap judgments about patients. Medical Economics 2002;2:48.