Dressed for the Part

Before I started practicing as an emergency medicine physician, I was told stories by my seniors of fantastic diagnoses made from the doorway of a patient's room. A chief complaint and an ocular pat-down in the first 5 seconds of entering the room, and  the diagnosis was made on the spot. Of course the workup was still performed, but it was considered a right of passage to spot the appendicitis from the door, even before hearing the story. Sometimes a patient's appearance can be read just like that, their body putting out a message that a trained eye can pick up. Appendicitis is the most common, but others such as a urinary tract infection, pregnancy, stroke, and a heart attack happen frequently. Studies have shown that this skill, called "clinical gestalt" is as reliable as some of the most well established risk stratification tools we have. 

Of course, there are plenty of times when we feel this way and we are completely wrong. Every physician has been humbled by a positive result for a test they considered not ordering. These are things that happen every day, and on their own, are not noteworthy.

I've noticed a different phenomenon as well. This phenomenon occurs when you ask the patient to adopt the role of a sick person, and this adoption manifests as symptoms and findings the patient doesn't even have. It goes like this: Take a healthy 20 something old patient with an innocuous complaint (runny nose), pluck them out of the waiting room, put them in a gown and under a few warm blankets, and watch the symptoms appear. Someone who was laughing and walking comfortably on their own before you put them in the stretcher and dressed them up, is now transformed. Voice is muffled, they have a hazy, glossy look about their eyes, and feel too weak to try a sip of water. Furthermore, if you suggest a symptom, they will suddenly remember that they did indeed have that at some point. We've all seen how a leading question can make symptoms magically appear (you've had blurry vision as well with all this toe pain? Of course you have) and how this can create a never ending search for the diagnosis that puts it all together. In this case, putting the patient in the appropriate setting makes them "act out" in a sick manner.

What then happens is that you work the patient up, and find a pristine set of lab work and imaging. The patient is given minimal to no intervention, but upon being told that they are okay, they instantly perk up and state they feel much better. I understand the therapeutic affect of being told you aren't seriously ill, but this transformation is not just a change in mood. They appear stronger, more vigorous, have better posture, and even their examination can improve. All of this seems plausible, but the sheer magnitude of change has often caught me off guard. Many times, when I've gone into a room perplexed that despite how ill a patient looks, I've got nothing to work with, the news that their testing was normal changes the patient so drastically that I find myself confused. There is no doubt that a subset of patients play up their illness to be able to get medication and more testing done, but I believe that the "situational affect" still exists. Its fascinating to see, and shows how powerful our subconsciousness can be. 

This affect has been studied in several other settings. There have been experiments when people have been dressed as law enforcement officers or prisoners and reacted by behaving more authoritatively or riotously. This is of course the famous Stanford Prison Experiment, and is a study taught in every entry-level psychology course, but I've never heard of this concept expressed in the medical setting. There is a subtle balance at play here, where the patient's augmentation of their sickness is weighed against that same gestalt I mentioned earlier. In an otherwise ordinary chief complaint, watching the reconciliation of these forces can make an encounter much more amusing.