The Three P’s: Patience, Politeness and Persistence
I remember a case from a medical elective I did in rural West Africa in 1980. At that time I had been working for a week in a hospital with a missionary physician whom I greatly admired. One day he asked me to see a young patient with chronic abdominal pain and after examining her I reported back that I thought it was possible she might have a chronic parasite – something not too unusual in that community. We proceeded to do a battery of blood tests, stool tests, and some rudimentary x-rays. But of course in those days in Africa we didn’t have the luxury of an ultrasound, CT scan, MRI, endoscopy or colonoscopy. In fact, the nearest specialist was an 8-hour drive away.
The patient lived with her family in a small house in our village and when her results came back we visited her with the news that we had discovered some parasites. Naturally, we proceeded to treat her with the appropriate antibiotics and she improved for a week or two until the pain suddenly came back.
The return of the condition was unwelcome news. The patient was disappointed we had not fixed things completely and since we were at a loss for what to do next she decided to seek another opinion, this time from the local traditional healer referred to as a “Ju-Ju Man.” Despite my initial skepticism my colleague was supportive of the decision and invited me to attend the healing ceremony that evening. It was then that I witnessed something truly remarkable.
The Ju-Ju Man was highly respected in the community. He asked the patient to lie down on a mat while her family sat expectantly in a circle around her. The healer then stood up, presenting to the crowd a bottle of medicine in both hands. He loudly appealed to the world in what appeared to be prayer while the patient remained quietly cooperative on the floor. He then stood over her and placed a bare foot firmly on her exposed abdomen. She appeared to be in some discomfort but remained quite still. Then to my surprise he raised the bottle and while continuing to hold his foot on her abdomen drank the medicine himself. To my absolute fascination the patient appeared to obtain immediate relief. His work done, he then stepped off and helped her stand up, moments later quietly walking away. Later she explained that the spirit of healing had literally passed from her healer into her own body.
I’ve never really been sure what happened that day in Africa but what I’m sure of is that any hard-to-diagnose condition relies a great deal on faith. Faith in the process of diagnosis and treatment—faith in yourself, faith in your physician and faith in the accuracy of the tests being performed.
Being a patient can often be difficult and frustrating, especially with a persistent abdominal condition. A careful and often repeated history and physical examination is a critical starting point. Your physician must be able to see you when you’re not well—at the time when you’re actually having symptoms. Physical findings are then correlated with the symptoms. Your doctor probably won’t put a bare foot on your belly but may feel it carefully. This may seem archaic, almost voodoo in the age of advanced technology, but it is vital in order to avoid unnecessary or painful tests.
You may be asked the same questions more than once so that both of you have the symptoms well in hand. Then a careful systematic choice of tests in a sequential fashion begins. The easiest and least intrusive tests start first (for example blood and urine tests) then perhaps stools tests—inconvenient and unpleasant but critical to identifying things such as infection, inflammatory conditions, and parasites from travel. The next step may be attempts to get a picture of your anatomy by using ultrasound, then perhaps CT scan and an MRI. These latter tests can be conducted with contrast enemas or IVs that provide more detail but are more unpleasant. Intravenous dyes can also be added but this presents other risks in terms of your kidneys or allergic reactions. You and your physician must discuss the relative risks versus benefits of these more advanced and invasive tests because they involve radiation and surgical risks. Finally, we try to actually look inside using endoscopy, colonoscopy or even laparoscopy. This always involves greater risk. Your physician can advise you on the rate of common or rare complications with each test. For example, colonoscopy carries with it a risk of rupture of the colon, roughly once per thousand procedures depending on the centre studied. However, other less severe risks also apply, such as bleeding, sedation side effects or even missing a lesion.
Tracking and eventually finding a solution to any condition should be a partnership between patient and physician. Hard to diagnose often means ruling out sinister or life threatening conditions as a priority. Generally speaking, with modern medicine this is usually straightforward. After that it becomes a matter of finding a problem with the function of the GI tract. This can be more difficult. For example, the most common default diagnosis for gastrointestinal problems is Irritable Bowel Syndrome, a functional condition that affects a majority of us in our lifetime at some point or other. Regardless of the final conclusion, if symptoms persist, it is critical that we maintain an open mind and seek re-evaluation at appropriate intervals.
Lastly, the key elements to a good gastrointestinal diagnosis are “The Three P’s”… Patience, Politeness and Persistence. These apply equally to physician and patient. You can see that my young African patient had the same qualities. And so did her healer.