After practicing general internal medicine for 25 years, one thing had become clear to me. Well, perhaps more than one, but the pearl I want to share with you is a doozy.
What is this shing little gem, you inquire?
This is it, and thanks for asking. For a patient you’ve seen for many years, who has always previously come in alone, when the wife comes in for one of his visits, healer beware! Light bulbs should pop in your head, your antennae need to be extended and their sensitivity level raised. It does not matter how well the patient himself reports feeling. Any protestations he he makes about how great he is feeling should fall on deaf ears. Trust me, friend, something is wrong, and woe be to the clinician who does not heed the large red flag whipping in that strong southern wind.
The specificity of this finding — wife newly in the exam room — is very high. Careful studies done in leading clinical venues, like my clinic, reveal a fals positive rate asymptotically approaching zero.
One of my very nice 60-year-old patients, whom I’ll call Mr. Simpkins, comes in twice a year for management of his diabetes, cholesterol, blood pressure, and sundry other chronic conditions. He is a joy to see, since he is one of those uncommon people who rarely has any complaints. I can’t help but love patients whose most common words are, “Fine, doc. I’m just fine.Sure can’t complain.” This is music to my ears. At his most recent visit a few months ago, all his screening labs were as normal as they could be.
Then, one Wednesday in May, I was trying to wade through one of my increasingly difficult work days. Midway through the morning, I noticed my next patient was Mr. Simpkins. My memory is not what it used to be (there’s another clinical pearl here, but that’s for another day), but I seemed to recall that I’d seen him recently. Fifteen mouse clicks on the electronic record later, I confirmed what would have taken me a couple of page turns back in the 20th Century, that he indeed had been seen two months earlier and his labs were all stable.
When I walked into the exam room, Mrs. Simpkins was sitting in the visitor’s chair. I had never met her before. She looked to be about the same age as her husband, was well-kempt, and a bit on edge.
I introduced myself to her, then turned to Mr. Simpkins and asked him why he’d come back in after only two months. He rolled his eyes, threw his hands up, and derisively said, “Ask her!”
I turned to Mrs. Simpkins and asked her what was going on. “He’s sick!” she said. “There’s something wrong with him and you better find out what it is.”
Mr. Simpkins interjected himself into our conversation and in a loud voice said, “Woman! I told you I’m fine.”
“No, he’s not,” she said, ignoring the man sitting on the exam table and directing her comments exclusively at me. “He’s dizzy! He’s tired! Something’s wrong.”
Mr. Simpkins again interrupted, saying, “Ain’t nothing wrong with me. Doc’s already run a bunch of tests and and everything’s fine. Let’s get out of here.”
Things continued in this vein for a few more minutes. I tried to elicit some symptoms from Mr. Simpkins, but his review of symptoms was decidedly negative.
A quick exam didn’t show anything.
So here I was, facing a small predicament. His tests two months ago were fine. He felt well. But his wife maintained something was wrong. What to do? Hmmm, I thought, wife newly in exam room. Large red flag. Follow your instincts.
So I turned to Mr. Simpkins and said, “I hear what you’re saying. Maybe something is going on with your husband, or maybe not. I just ran a complete battery of tests on him two months ago and everything looked fine, but I know things can change, so let’s repeat them. After we see the results, we’ll review how your husband is doing.”
She smiled triumphantly and shot her husband a “see-I-told-you-so” look.”
Long story short, on the repeat labs, his platelets were very low at 20,000, he was anemic with a crit of 25, and his white blood cells were quite low at 1,100. And on a bone marrow biopsy, he was found to have leukemia.
Moral of this story? When a red flag is flying in your face, heed the warning.
Another case from a month earlier, which I’ll digest down to its essence. Husband with well-controlled asthma and not much else came in with his wife, who rarely accompanied her husband to his visits. She’s worried about his asthma getting worse, with more coughing, and some acid reflux symptoms. Large red flag. Two months later he is dead from metastatic esophageal cancer.
Over the years, I’ve made timely diagnoses of innumerable cancers, myocardial infarctions, serious infections, and various other ailments, all from paying attention to this red flag. Had I not been tuned in to this warning mechanism, the diagnoses would likely have been delayed. As I said earlier, the false positive rate on this clinical finding is essentially zero.
One cautionary note: the opposite sign — husband newly in exam room — has no clinical significance whatsoever. This is appropriately referred to as a red herring, not a red flag. All attempts to discern any clinical relevance from the husband newly appearing have been futile. Most probably there were no good shows on TV that day or he was looking to extricate himself from some home project.
So, my friends and colleagues, heed these words and pay attention to this sign. Your patient may not initially appreciate it, but after you make an astute diagnosis, they will praise your incredible expertise. And you can thank the wife for newly appearing in the exam room.
(July 2009)