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There's an aphorism taught to medical students that goes like this: "Listen to the patient. He is telling you the diagnosis."

The obvious intended message is the apparent profundity found within simplicity. Ignore the newly acquired ocean of knowledge swimming around in your brain, the master says to the apprentice. Instead, do something far more basic and humanistic: really hear your patients.

It sounds so easy. It isn't -- and for several reasons. A few years ago, a then-new piece of technology made me acknowledge just how often we don't do this.

To Believe or Not to Believe?

I'll never forget the case that made me realize this. I was working in New York during my residency. I was evaluating a white male patient in his 40s who had come to the emergency department (ED) looking for a diagnosis and treatment. He told me he had new pain and swelling in his left leg over the last couple of days. He was a truck driver, and somewhat overweight. Other than that, he had no serious medical issues. He had no recent injuries that he could chalk the symptoms up to. His symptoms had been worse yesterday, but he still felt them today and he finally had a chance to come get checked out.

At this point, I could have followed the aphorism without even doing a physical examination and worked him up for a "deep vein thrombosis," a blood clot in the veins that is large enough to cause circulation problems and potentially become dangerous if it were to dislodge and float its way up to the heart and lungs.

Indeed, that's another pearl of wisdom that is taught in medical school, and a less pithy version of the aphorism: the history (i.e., what the patient tells you) contains far more diagnostic information than the physical examination. Often, that is true. Patients think that our physical examination maneuvers are what distinguish us doctors from laypeople. To some extent that's fair. But our real skill is interpreting the meaning of the histories we are told, tailored to the patient's situation. The same words spoken by a 30-year-old who is healthy and a 65-year-old who has medical problems are correctly interpreted differently by doctors. Both may be coming to me with legitimate concerns. Yes, I believe them both. But I do not believe the meaning of their words are interchangeable, and that's precisely because of the differences in who they are -- their risks.

Of course, this brushes aside insidious problems about who doctors are more likely to believe. Many of you will have noticed that the old aphorism we started with uses "he"; of course, defaulting to male pronouns was idiomatic of yesteryear writing and speech, but it's hard to ignore another implication there. If today, I said "Listen to the patient. She is telling you the diagnosis," it might be interpreted as some kind of sociopolitical statement. Believe women when they tell you their symptoms. Don't be one of those doctors who doesn't!

Indeed, there's sexism, racism, ageism, classism, and other forms of discrimination to overcome in all of these doctor-patient interactions. I'd certainly like to think I'm immune to these forces, but of course that's impossible. Instead, I try to combat them, both by acknowledging I probably have blind-spots, and, more actively, by asking a different question. I do not think to myself, "Do I believe what this patient is saying?" Rather, I think "Is it likely that other doctors might shrug off what this person says?" If the answer is yes, I'm apt to do more testing than I otherwise would have. It's not easy though. If I truly believed every word that each of my patients said I'd end up ordering dozens of unnecessary tests each day, wasting time, money, and the very patients I'm trying to help.

Back to my patient, the trucker. I examined his legs. "I'll be honest," I said, "I don't think your left leg is any more swollen than the right leg." He showed me a small area on his left calf where it hurt the most. I couldn't feel anything unusual there and his skin looked normal, other than a few areas of "hyperpigmentation" on both shins -- tiny red spots that indicate the long-term mild effects of decreased circulation. This is common in people who spend a lot of time sitting, and excess body weight can contribute.

I was not "impressed" -- meaning I was not alarmed. This was not a broken bone or sprain nor an infection. From the standpoint of an ED doctor, the possibility of a blood clot in the veins was the only reasonable remaining concern.

On one hand he was a truck driver. That means many hours of uninterrupted sitting, a known risk for blood clots. On the other, there were no signs of one. I had to decide whether to order a Doppler ultrasound of his leg or not. The test would add hours to his ED visit, which seemed pointless if I thought the odds were low enough.

I started to give him "the speech" -- the one where I explain why I do not think any testing or specific treatment (other than ibuprofen or something) is necessary. Some patients are happy to hear that they don't need tests. Others take it as a sign of disrespect -- that I am dismissing their symptoms, or worse, not believing them. I can't quite remember what his reaction was, which tells me it was probably somewhere in the middle.

The Power of a Picture

Then the patient did something that I'll never forget -- and is the reason I'm writing this now. He pulled out his cell phone and showed me a picture of his left leg from the day before, which had been the last day of a multi-day delivery spanning well over a thousand miles of road. His leg looked completely different in the picture. It was noticeably and impressively swollen.

That's when it hit me. I had thought I believed him when he told me his leg had been swollen the day before. But on some level, I must not have. Based on my physical examination of him, I had determined that no further testing was necessary. But his leg was so damned swollen in the picture from the day before that it changed my mind. If he had been this swollen on the day I evaluated him, there would have been no question that he needed to be tested for a blood clot.

I ordered the Doppler ultrasound. It was negative. My initial impression had been right. No blood clot. What caused his leg swelling? Who knows. It could be that he had some small clots in tiny superficial veins -- not enough to be a dangerous deep clot, but enough that when the leg is slightly compressed by the truck seat, it was causing a slowdown in the rate of blood return from his foot back up to his heart. I told him to try to adjust the angle of his seat or add some kind of cushion.

Nowadays, patients come in with pictures of themselves quite often. The information from a "selfie" can be extremely useful. If a patient has a rash all over their arm, and a picture of themselves from 4 hours earlier in which just a small rash on their hand was visible, that gives me a strong sense that the rash is spreading quickly.

So, now, when I am discharging a patient, I often instruct them to use the camera on their phone to take "serial selfies" every day (or more often in some cases) to document their symptoms. That way, if something changes -- or doesn't -- they have a concrete way of knowing that and can offer an easy way for their next doctor to understand what has been going on.

The serial selfie is, in essence, becoming a standard medical test. Over time, it has crept its way into medical practice. My spouse and I have uploaded pictures of our kids' rashes to the "patient gateway" app, and those pictures have clearly influenced the medical decisions of our pediatrician (i.e., Does the child need to come into the office? Do they need an antibiotic?).

It's remarkable how the patient-provided selfie went from unheard of just a decade ago to being a completely normal part of medical evaluation today. Serial selfies probably save patients time and money. And, as I discovered, they can also quickly change how doctors interpret the words that their patients say. Surprisingly, pictures can change how we listen.

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