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Numerators and denominators

“A fifty two year old female comes in and encapsulates her presenting complaint in four short words: ‘I just feel blah.’ As Sandy Burstein noted, the family practitioner generally has less to begin with than, say, a nephrologist, who knows when referrals come in that their problems are in their kidneys. ‘Blah’ is a psycho-medical condition at the center of square one, and that is where the family practitioner’s diagnosis begins.” – John McPhee. Heirs of General Practice. Farrar, Strauss, Giroux. New York. 1986. p. 69.

 I was listening to rounds the other day, when a distinguished researcher was discussing a new screening test which promises to be a game changer in the early diagnosis of many cancers. It was inspiring to see the coming to fruition of many years of dedicated work and inquiry. Then out of the blue came a statement which rocked me back on my heels. “Of course, we get all these patients, where the GP has completely missed all those symptoms, but we as specialists really know what the implications of these symptoms truly are and will investigate them properly!”

I guess she was not aware of who her audience was. To be fair, she also said that as a tertiary care specialist she didn’t know much about primary care.  “Damn right!” I thought. “You have no idea.”

Specialists and super-specialists see a highly selected group of patients. They are pretty sure which organ system they are working with; they are almost assured that the issue is physical or at least one of a limited number of functional conditions. 

For family doctors anything can happen. Patients come in with a story of “not rightness.” Only about 60% of cases will have a clear diagnosis, the other 40% of cases in a family doc’s day are more elusive. 

When I went to medical school, back before the flood, I drank the McGill Kool-Aid, thinking that only second-class people went into family medicine, which is why I wandered around in two different specialties before finding my true calling. Honestly, seeing illness when it is fresh and as yet undefined is one of the great joys and challenges of family medicine. Symptoms that do not yield to diagnosis after a reasonable work up are not all the same but they do have some distinct patterns. 

In the mainstream there are two paradigms that are widely admired, they even make TV shows about them. These are the subtle, early or unusual presentations of common disease or the presentation of unusual disease. In these cases knowing the patient well helps the practitioner see the subtle changes and understand the patient’s reality.  

Once upon a time, I’d just started my practice in a tough neighbourhood in Montreal. One of my patients was a woman in her fifties named Martine. Martine had a rough life. She was on welfare, an alcoholic, smoker with bad diabetes and she had three adult daughters with three different fathers.  

One day Martine came in really rattled and upset. One of her daughters was living with a man who was previously convicted of child abuse. The child welfare agency was understandably hesitant to allow her two young children to live with this man, and her daughter declared that she could not live without him. The judge decided that the children could stay with their mother if Martine moved in and assured that the abuser was never alone with the children. At that moment Martine felt her heart pounding, her breath was laboured and she fainted. After a brief visit to the ER she was diagnosed with a vasovagal. 

A few days later she was in my office. “I hate him so much” she said, clasping her fist in front of her. “Now I have to be with the kids all day. As much as I love them, I am getting tired.” 

She continued, “every day when I walk to the park, I have to stop and sit down at the same bench and rest.” My eyes widened as the penny dropped, and a few weeks later she had her coronary bypass. Here was the classic situation where my knowledge of the patient, careful listening, and understanding of her risk factors allowed me to make a diagnosis of an early and subtle presentation of a common disease. This type of pick up is what is lauded in classic medical education, along with the diagnosis of rare diseases (see A cookbook diagnosis) but is not the only, or even the most common, form of undifferentiated illness. 

Another patient, Abigail, came to the clinic complaining of chest pain. The pain would come and go unpredictably but was mostly there in the evenings. She also had headaches that were sometimes blinding in intensity, but did not sound like migraines. She was quite young, newly married, had quit her job in finance because her husband wanted her to concentrate on the family, with the view of having children very soon. He would come with her to every visit. He was handsome, extremely charming and very deferential to me. “Listen to Doctor Perle, Abby.” He would say. “She knows what you need to do.” 

This behaviour triggered alarm bells in my head. I have met this kind of man before. I worried that Abigail was being abused. I did a basic work up but there was nothing that suggested any serious disease. There was however lots of illness. She was becoming very debilitated. When I managed to get her alone, and asked her how things were going at home she said. ”It’s a bit difficult, he loves me so much, I love him so much. I try to be a good wife, but I keep messing up.” 

This was a delicate situation. I struggled to think of what to say. “Sometimes, our bodies know things that our brain is not ready to hear. Your symptoms could be related to stress. Perhaps it’s hard to try to fit into someone else’s expectations. In the meantime let’s do some physio and,  maybe you should join an exercise group so you can hang out with some other young women your age.”

“Oh,” she said. “Paul thinks those kinds of things are a waste of my time. He says I should concentrate on learning how to be a good housekeeper, before the kids come.” It took another two years before she was able to link her headaches and chest pain to Paul’s coercive control, and it was only after her daughter was born that she was ready to get out and divorce her chest pain. In this case her symptoms were clearly a physical manifestation of the psychological distress that she could not allow herself to feel. 

Then there was Maria, who had a chronic cough and chest pain, which she had for many years. She attributed this cough to having been exposed to some toxin or virus, or fungus in the displaced person’s camp she lived in after escaping civil war in her country. 

Recently, her house burnt down and she lost almost everything. The chest pain became worse and she believed that the fumes from the fire had retriggered what ever the toxin was. To complicate matters, she had coronary artery disease, hypertension and rheumatoid arthritis. She had undergone a bypass, and her ribs were always tender. She was followed by four or five different specialists, was on 10 or 15 different medications, her doctors were all frustrated by not being able to help her. The allergist could find no allergy. Treating her h. pylori and reflux made no difference. She underwent cardiac and respiratory investigations repeatedly. The specialists would write back: “After our work-up and treatments we find the patient does not have a significant diagnosis in our specialty and so we return her to your care.” 

All we could do is try and support her in her illness and keep doing our best to watchfully wait without over investigating. A challenge for anyone. This is, I believe, the most common type of undifferentiated illness, where a complex interaction of the patient’s life history, medical diseases and the side effects of their treatments all interact with their personal psychology and belief systems to make their lives too painful to bear. 

Finally, thinking about COVID, I remember just before the pandemic started, my family medicine obstetric colleagues noticed a huge increase in the number of miscarriages, premature labours and stillbirths among our Hasidic patients, many of whom had been down in New York for the Purim holiday. I called my friend in public health, and they were intrigued. Not long after, the reports of COVID’s effects on placental function started becoming known. This is an example of how family medicine, with its finger on the pulse of the community, can be the surgical arm of epidemiology. We are often the first to see emerging diseases, and are the ones to implement its treatments.  

So, yes, family medicine may not actively investigate every chest pain and headache as aggressively as our specialist colleagues might. That is because our denominator is much larger and our numerator so much smaller than theirs, and we must use strategies that will best care for our patients, and in the process not bankrupt what is left of our healthcare system. 

Dr. Perle Feldman would like to acknowledge the contributions of Drs. Nick Pimlott, Curtis Handford, and Karl Iglar all of the University of Toronto for their work with me in formulating these ideas.