The Physician’s Bias

The last patient of the day had been waiting for more than an hour for her appointment. It was one of those days at the clinic when everything simple became epic. The computer broke. The secretary was ill. There were three “Gladys Thompsons” on record. This Gladys was the only Gladys Thompson whose file wasn’t pulled. And it was 6:00 p.m. after a busy night of being on call. Time to go home.

“Mrs. Thompson, would you like to come with me, please? Sorry for the wait!”

As a medical student, I see patients first. Then I discuss my findings with the attending physician. The attending physician and I go back to see the patient together and conclude whether or not my diagnosis was correct and if the findings of the physical examination were accurate. This was the last day of my neurology rotation with the attending physician.

After a bit of discussion about her hometown, I asked, “What brings you to the clinic on such a beautiful day, Mrs. Thompson?” In a millisecond, I was bowled over by a list, read like the Magna Carta, from a small notebook. “The problem began July 10, 1970. My feet are stuck to the ground. I can’t stand without feeling off balance, and then I start to shake. It all started when my husband died. I can walk for a long time without a problem, but I can’t walk across the room without feeling off. I have sore calves and a sore back. The world spins when I am in a public place. I get nervous on the dance floor. I was told that it was anxiety and keep going to the psychiatrist, and my two sisters have M.S.”

The list continued, but I was distracted by the manner in which Mrs. Thompson presented herself: terse, stressed, and cathartic. Every hair was in place. I peered at the list. Every “t” was crossed, and every “i” was dotted with immaculate precision. The inclination of her writing was precise, as though Magellan himself had navigated its angle: 1991: ingrown toenail; 1993: admitted to psychiatry for 2 weeks after the death of her husband. A full life with a lot of health problems marring its path. Mrs. Thompson had also tried a shelf full of medications for her mental health. During her 68 years of life, there had been a number of stays on the psychiatry ward for depression and anxiety.

“I am tired of being told this is just anxiety,” she said with decades of annoyance culminating in just one sentence. “My doctor says ‘just relax,’ but you must believe me that there is something more. I know it’s in my head, but I can’t control it.”

Mrs. Thompson’s neurological examination demonstrated breakthrough weakness of the upper extremities. She was unsteady when asked to stand. The longer she stood, the more dramatic it became. She had walked into the office without difficulty and even picked up her list when it fell to the ground. Her family physician had seen her for years, and finally, more to placate her request than anything else, Mrs. Thompson ended up at our door, reading her list for the last time.

“The physician’s bias,” stated the attending neurologist, “must always be that the patient has a disease and is not purely complaining. Not only does that make the medicine more interesting; it means that you will not miss a treatable problem. She may not have anything, but it is our responsibility to think of all of the things she could have.”

We entered the examining room. Mrs. Thompson stood up to shake the attending neurologist’s hand. Within seconds, he said the diagnosis “was obvious.” He continued with the examination, seemingly unsurprised by the lack of findings and wrote a prescription.

“Orthostatic tremor. You have orthostatic tremor,” he said matter-of-factly. “You are quite right. You may be an anxious person and that may be making this worse, but this is not only anxiety.”

“You mean all of these years I actually had something, and everyone thought I was crazy?” Mrs. Thompson had difficulty hiding the tears welling in her eyes. She used her list to dab them in turn. “Since my sister’s wedding, July 10, 1970?”

“Quite right.” Mrs. Thompson had seen physicians who had the wrong bias for 35 years.