How A Simple Doctor’s Visit Becomes Complicated

When i see a patient walking past my office towards the exam room I can generally recognize a ‘gout walk’. Obese middle-aged man walking on the outside of his foot trying not to put pressure on the great toe.

In the exam room the patient will tell me that there was no trauma. The skin has erythema and the joint has a diffuse effusion. There is no skin induration so I know there is no infection. And the patient states it started overnight with severe skin sensitivity with even the bed sheets touching it.

So that should be a super easy visit right? I walk in, ask the right questions, address pertinent positives and negatives, do a focused exam and make my diagnosis. Maybe I give a bit of information about gout and go over a brief purine restricted diet and am only interrupted by the patient saying that they eat nothing on that list despite their BMI matching my age.

The truth is that the sooner I jump on a diagnosis the longer the visit will take. I’m not saying that I’m always right but after doing this shit for nearly 8 years I do have some diagnosis that I’m highly certain of.

So, I drag the visit out, act like the information is really interesting and that I’m thinking. Then think out loud to tell the patient what it could be. I sometimes have to even image the gouty joint just to convince the patient. If I don’t then the patient will be unhappy with their visit, there is likely going to be a bounce-back which just clogs the system.

I wrote this post just so I can bitch about the patient/doctor culture in the US. I realize that a patient sometimes needs education and needs to be listened to and at least in the west also needs a lot of hand-holding. When I see the patient’s eyes light up from the attention I give their knee or other affected body part I actually feel sad for them.