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The Doctor's View: What's Left Unsaid

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Egan is a pediatrician in Jacksonville, Florida. Some names in this column have been changed to protect patient privacy.

Not so long ago, "Seth" was my one of my last patients of the day. The chief complaint listed on the chart was "nosebleed." His mother, father and grandmother were all squeezed into the room along with Seth, 4, who had only been to my office previously for check ups.

According to his mother, Seth had had a nosebleed the day before that stopped after a few minutes. Though he had never had a nosebleed before, they told me that he was a frequent nose picker, a habit his mother and grandmother assured me they had tried to fix. Sethís father also told me the little boy had had a fever three days earlier, a temperature of 101.3 that hadnít been elevated since. Other than that, there seemed to be no worrisome symptoms: he was acting and playing normally, wasn't congested nor did he cough; he had no sore throat or headache, no stomach aches, nausea or vomiting; his appetite and sleep habits were normal; he had no unusual bleeding tendencies and he did not bruise easily. His physical exam revealed nothing out of the ordinary. A quick scan of Sethís chart reminded me that his familyís medical history was equally unremarkable.

While I was talking to Sethís parents, Seth climbed up and down from their laps, explored the infant scale and took a matchbox car out of his pocket and raced it along the floor. In every way, he appeared and acted like a healthy active four-year-old boy. I summed up my findings to Sethís family, but they just sat and stared at me blankly, making no attempts to stand or get Seth dressed.

I again reassured the family that Seth was the picture of health and that the nosebleed was most likely the result of some overzealous nasal hygiene exacerbated by recent cold weather. I walked them through how to treat nosebleeds if Seth were to have another one and the constellation of symptoms that would necessitate another visit to the doctor. Again, I was met with blank stares.

I told them how I thought the recent fever was most likely due to a brief viral illness and certainly if the fever recurred I would want to reexamine Seth. Again, I was met with blank expressions all around, except for Seth, who had found a stash of Pepperidge Farm goldfish in his motherís purse and was happily munching them. I then asked if there was any information I hadnít asked, if Seth had any other symptoms that I hadnít touched upon. "Youíre the doctor," Sethís father said.

Yes, indeed, I am the doctor — and given their body language, I was clearly not serving my patient or his family. I did a quick scan of my notes, performed a quick mental review of my history and physical and felt confident that I wasnít missing anything — except of course, what was worrying Sethís family. I scanned their faces slowly, but each one in turn looked away until I met eyes with the grandmother. She licked her lips, "My cousinís grandson had a fever and then a nosebleed and he died of leukemia."

I was so relieved to hear this that I got teary, as did Sethís family. Years of clinical experience told me that Seth did not have leukemia. He had no pallor or bruising, his spleen and his lymph nodes werenít enlarged, and the history of his illness didnít match. I knew he didnít have leukemia, but what mattered was that they didnít. A blood count performed two minutes later alleviated everyoneís fears, and after hugs all around, Sethís family left the office rather giddily.

I understand that patients or their parents are often so worried about cancer that they donít even want to utter the word. I also know that I am no mind reader and I can only answer questions if they are posed to me. The chief complaint may have been nosebleed, but their chief worry was leukemia.

Now when I meet new patients, I implore them to bring me their worries, not just their symptoms. And when faced with blank expressions, I am quick to ask, "Is there anything that youíre worried about that we havenít discussed?" Every now and then, I get an answer Iím not expecting, and we are all the better for it.

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