Stop. Look. Listen.
Solving medical mysteries with time-tested Q-and-A
Clifton Meador, M.D., cured his patient’s three years of diarrhea with two simple questions. Agnes was a 27-year-old secretary who had had every test imaginable to find the cause of her persistent diarrhea – upper and lower endoscopy, several barium studies, a biopsy of her small intestine. She even had her gallbladder removed when gallstones were found. All the tests were normal and the diarrhea continued. Some physicians told her she might have early stages of ulcerative colitis or Crohn’s disease. Another told her she might need to have her colon removed and referred her to Meador for further evaluation. He agreed that all of Agnes’ tests and lab results were normal. He probed into the frequency of her diarrhea, and asked her to keep a diary with close record of what she ate and the time of each bowel movement, though no pattern emerged. Then Meador asked his two signature questions: What are you doing in your life that you should stop doing? What are you not doing in your life that you should be doing?
"I had found that these two highly unspecific questions provoke a deep memory search in patients with symptoms of unknown origin. If you think about the wording of these questions, you will see that they are limitless, and therefore they provoke a search of every aspect of one’s life,” writes Meador, professor of Medicine, emeritus, in his latest book “True Medical Detective Stories,” which recounts Agnes’ story along with 18 other cases of mysterious diagnoses.
Agnes said she knew her boss was embezzling money from the company, and she was torn between doing the right thing by reporting him and turning a blind eye to keep her job, but insisted it didn’t have anything to do with her diarrhea.
Meador didn’t see Agnes for several months, but when she did return to the clinic, he barely recognized her. She had a new hairstyle, stood erect and was smiling and laughing with the staff. She said she had reported her boss, resigned from her job and felt a great weight lifted from her. Although she still didn’t think it was related to her job situation, the diarrhea had ceased.
“Listen to the narrative of the patient. Just listen. Say ‘tell me your story,’ and then sit and listen,” said Meador, who retired last fall from 13 years directing the Meharry-Vanderbilt Alliance.
Through a career of small-town private practice, directing the National Institutes of Health Clinical Research Center in Alabama and academic medicine at Vanderbilt, Meador has solved dozens of medical mysteries of his own, in addition to collecting many more from colleagues to retell in his books. For him, cracking the case isn’t knowing what test to order or obscure reaction to look for. Diagnosis truly comes down to listening to the patient and getting them involved in analyzing their own body.
“Sooner or later patients will tell you what is wrong if you listen carefully, especially if they are gently directed to look around themselves and wonder. Sometimes a physician has to listen for a long time, but it remains true that patients are their own best medical detectives,” he writes of perhaps his most famous case, “Dr. Jim’s Breasts.” Medical writer Berton Roueché, a hero of Meador’s, recounted that tale in his book “The Man With Two Breasts.”
Dr. Jim was 76 when he began to have abnormal breast growth. Meador looked for a tumor or some other explanation for an increase in estrogen. Dr. Jim laughed off Meador’s request to keep a journal of his habits, but as soon as he did, his wife realized the vaginal cream she used contained estrogen, and Dr. Jim was absorbing it through their sexual contact.
“All diseases or illnesses arise out of the life story of the patient,” Meador said. “You just have to take the time to listen to that story.”
How’s the Family?
When Michael Fowler, M.D., an assistant professor of Medicine who teaches the Physical Diagnosis course to second-year medical students, was an endocrinology fellow in 2002, he was called in on a Saturday afternoon to see a patient who had just had prostate surgery and couldn’t stop urinating. Fowler initially thought it was just high blood sugar, but says he’ll never forget the sight that greeted him in the hospital bed.
“This fella was sitting up with a pitcher of water in each hand and one of those bendy straws sticking out of each one. He was double-fisting pitchers of water.”
With blood sugar at 150, not high enough to cause such excessive urination, Fowler knew a thorough history and physical was in order.
“The physical exam wasn’t really remarkable for anything, but I get to talking to him and he said he’s always thirsty, and it is nothing unusual for him to drink a lot of water and pee every hour or 30 minutes and get up three or four times a night.”
He was even pinned down in a foxhole during the Battle of the Bulge in World War II and braved the gunfire to get water from a creek.
“He said he would rather get killed really quick by a bullet than die of thirst in the trench,” Fowler recalled. “He told me that drinking water to him was like drugs are to a dope addict.”
During family history questions, the patient revealed that others in his family also drank a lot of water, and by the age of three or four the family would classify children as being a “water dog” or a “non-water dog.”
From all of this information, Fowler suspected the patient had diabetes insipidus in which a person cannot concentrate their urine, either because the body does not produce the necessary hormone or the kidneys do not listen to the hormone.
A test dose of the hormone was given, and the excessive thirst and urination stopped. The patient’s family agreed to further testing, and Fowler and colleagues described the second-ever case of a mutation in the vasopressin gene, which regulates the body’s water retention.
“If you’re the first person to describe a mutation like this, you get a disease named after you. If you’re the second person, you just get to tell medical students about it,” Fowler quipped.
“I use this long-winded story to remind medical students not to forget about family history. You are going to find rare disorders or new disorders that you would never have discovered otherwise.”
Context Key to Cracking Case
To crack a medical mystery, Anderson Spickard III, M.D., M.S., associate professor of Medicine and director of the Third-Year Medicine Clerkship, emphasizes figuring out what is normal for patients and looking at their case in the context of their lifestyle. A great example is his patient whose chief complaint was shortness of breath at mile 11 of his runs.
“The idea that goes through my head is, ‘You’re fine! Next patient!’ But we listened and challenged him and sure enough, we uncovered atrial fibrillation, a concerning heart rhythm, was occurring several miles into his workouts,” Spickard said.
“I found him in the back in the garage on a makeshift mattress in a closed room with no door or windows and a heater going. Ended up diagnosing him with carbon monoxide poisoning,” Spickard said.
“House calls often end up being a way to crack a case. They’re a way to get more information from the patient and more collateral data from the family. These visits allow me to see the contextual issues of the set-up at home as well as clearly communicating my commitment to the patient.”
Of the 1,400 patients Spickard follows, at any given time he has six or seven on his “A list” – cases he either can’t crack or are very complex. With these patients, he’ll often put all of his notes away and start over as if he’s met them for the first time.
“My angle is less ‘crack the case and they carry me out triumphantly on their shoulders’ and more ‘enter the cracks of the case and belong there in those difficult places and see my patients and their families through it.’ The Hollywood attraction of the Sherlock Holmes of internal medicine is equally matched with the dignity and honor of entering in others’ suffering and making a difference,” he said.
“It’s exciting to go down the path and keep turning over rocks and never knowing what will break open the case. But that’s more the exception than the rule.”
In the case of a grandmother from Cameroon, Spickard found that to be all too true.
“Common diseases are common for a reason,” he reminded himself as his longtime patient returned from one of her extended visits to her homeland complaining of feeling terrible and losing weight. She added offhandedly that she thought she also had malaria and typhoid fever.
“What was I going to do with that?” he exclaimed. “What are the initial laboratory evaluations needed here? I had no idea what to do. But knowing she was diabetic and that ‘common things are common,’ I took a focused history and realized she had gotten her medicines unorganized and her sugars were way off. She did not have malaria and typhoid fever; she had renal failure, a very ‘American’ disease.”
Delay the Diagnosis
In “True Medical Detective Stories,” Meador tells a similar tale of a hospital whipped into excitement at the prospect of a patient with an extremely rare case of xanthinuria. The protein xanthine is normally converted into uric acid, but people lacking an enzyme for the conversion experience kidney stones. The patient exhibited the classic pain pattern, requiring frequent doses of morphine. A series of student discussions and a grand rounds lecture were planned for this special case.
Then a nurse caught the patient picking her gums with a pecan shell, putting drops of blood and bits of nut in her urine to mimic kidney stones. Pecan shells are loaded with xanthine, and the patient had unknowingly created the perfect medical crime. The grand rounds was changed to a lecture on drug-seeking behavior.
Meador is an advocate for waiting as long as possible to make a diagnosis. “Once you label it, it’s over,” he said. “Medicine today is so ready to do a CT scan and MRI and draw a little blood and go right to the technology rather than listening them out. A lot of patients get locked in forever to something they don’t really have.”
Meador trained in Endocrinology and initially thought the field was going to be the end of all disease.
“I thought the physician would just find out what was wrong with the body and fix it. Give a pill and make it all go away. I now know what a long road it is to truly listen to the patient, separate all their different complaints and get them to look at patterns. But that’s what has to be done.”