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Spend enough time around certain doctors and you'll learn what kind of meat you are.... In US med schools, future Hippocrates learn to lump and not split -- "lump" together the patient's symptoms, meaning assume that all the symptoms are related. And, as it happens, most diseases and disorders lump well, because in general most patients suffer from clearly defined acute or chronic conditions. So let's say you're a doctor, any kind of doctor, and you see a thousand different patients in a single year. Of your patients, 995 show textbook or near-textbook signs and symptoms of your specialty's core illnesses, three show unmistakable codependent behaviors and just "want attention," and the remaining two have well-defined signs and symptoms that strongly suggest illness but have ambiguous or negative diagnostic results? What do you do with two-tenths of a percent? Cue Richard Dawson.... Top 5 answers are on the board: 1. Assume the two patients are not ill and suggest psychiatric counseling. After all, it's much more likely they're just drug-seeking. 2. Have your office staff contact the patient with the lab results. Cancel appointments with that patient until the patient quits contacting you. 3. Point to the negative tests, say "Doesn't look like I can help, but I may know someone who can," and recommend the patient to a peer in the same medical center with another specialty. Share the wealth. 4. Assume a possible false negative, run tests for likely candidates again, and/or add Tier II tests for possible but unlikely or rare conditions. If all tests remain negative, revisit Answers 1, 2, or 3. 5. Follow the logic in #4 but also check Medline, journals, and peers with broader experience for patients with similar case histories or presentations. Take the patient's case to Grand Rounds, if possible. Run multiple but different diagnostics for the same conditions. Well, which would you choose? How much attention would you give to that one- or two-in-a-thousand patient who doesn't fit the norm? What kind of meat is your patient? Medical professionals are like everyone else, with the same pressures we all face. When a carpenter bends a nail, she pulls it out and starts another because it's cheaper in the long run and works better. CFOs recommend selling off the slumping business unit or outsourcing the cost center. Hospitals and medical offices assume a certain throughput of patients for the required (or more often, target) levels of income. But as patients we hope that medical care is more than literal or figurative bean-counting. We want to assume that the good doctor will listen, review, test, study, question, and resolve our issues, even if they're unhandy or unusual. We want to believe that we'll be believed. We want to trust and be trusted. Those of us who have fallen within the percent of a percent of patients know that the majority of physicians, regardless of specialty, follow their schooling and lump not only the symptoms but also the patient. The ill are homogeneous as hamburger, not distinct because they don't require distinctiveness for diagnoses. Those patients who show up and don't fit the homogeneous mixture, don't look like a burger, are most likely in the office for reasons other than medical care, are the needy, the attention-mongers, the sawdust not really requiring or worthy of a doctor's care. Some of us aren't sawdust or hamburger. With the incredible richness and variety of the human genome, and with the great experiment that's resulted in the largest genetic melting-pot in the history of humankind, it is always possible for that single patient to be singularly unique in some way. A small percentage of people with western European ancestry are resistant to HIV, most likely because of their great-great-etc. forebears' exposure to and survival of yersinia pestis, the Black Death. Sickle-cell anemia is debilitating but those with it will never get malaria. The Japanese equivalent to the FDA requires that medications be tested in Asian populations before approval for marketing in Japan, even if the drug has been extensively used by non-Asian populations, because there are differences in the ways certain medications are processed within the Asian physiology. Medical research talks about "targeted therapies" and "the right drug for the right patient." Yet today, in the doctor's office, it is too much of a stretch to assume the test may be inconclusive because the person being tested is not within the bell of the curve. If you're sick, if you know you're sick, if you've been brushed away by doctors like so much sawdust, remember that you're a percent of a percent of the patient population. The doctors who see only hamburger aren't going to recognize you and your illness. You must take control, center yourself, start looking for the percent of a percent of doctors who answered #5 when Richard Dawson came knocking with his questionnaire. Doctors provide a service -- an important service, but a service nonetheless. If you're not satisfied with a plumber, tailor, or veterinarian, would you hesitate to stop calling on him or her? Patients are not hamburger. People are not meat. Doctors are not infallible. You can take control.

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