Starting from scratch  

The patient, Dr. E, was a 59-year-old woman recently admitted to inpatient psychiatry for worsening depression. The initial history obtained in the emergency room cited a one-year history of low mood, anhedonia, and decreased concentration. In collaboration with her outpatient psychiatrist, Dr. E had recently tried three different antidepressants at maximum dosages for an appropriate duration, but her symptoms persisted.   

When I see patients for the first time, I take it as an opportunity to start “from scratch.” Typically, I go in with a blank slate and ask the questions that naturally come as they share their background information. I then go back and review the other information documented, from prior encounters or notes taken during my first encounter. Sometimes, patients are offended and ask, “Didn’t you see my notes?” or inform me, “Someone already asked these questions.” I tell patients that this is important for my process: to generate follow-up questions and new potential ideas about their diagnosis. Patients then typically re-engage. 

During this particular initial interview, Dr. E was transparent about her recent depressive symptoms. She noted that it had prevented her from working as a physician for much of the past year. The patient mentioned possibly not wanting to work as a doctor anymore and disclosed all of this with a sense of detachment. She was open and honest with her history, but sometimes it’s information from family and friends that helps bring the story together. 

Upon obtaining collateral history from her partner, additional information pertaining to the patient’s inability to work also helped create a picture of current symptoms. Specifically, Dr. E reportedly became indifferent to working and meeting her patient’s needs. By all accounts, before the onset of symptoms she was reliable, showed up to work on time (if not early), and completed her required patient notes and other documentation. However, following symptom onset, the patient’s partner noted that he and other family members had to assist her in and out of the car on a daily basis, and one time at her work office had to help “prop her up” at the desk. 

This additional information, the seeming indifference towards her responsibilities as a doctor, gave me pause in terms of the overall diagnosis. As a fellow physician, I’m acutely aware that most doctors often show up to see patients, even when sick themselves, rather than let them down (whether this should be the case is a subject of another discussion). Nevertheless, once a doctor displays indifference towards their craft, something is typically really wrong. It’s important to note that this indifference wasn’t apparent when I talked to the patient; it was in speaking with her partner, who described the process in getting her to work that created a different picture as I worked through a differential diagnosis.   

With a presentation unlike that expected for a well-respected physician, I expanded the differential diagnosis to include medical reasons why this patient may have been experiencing these symptoms. For any new onset psychiatric symptoms, it’s always important to rule out medical causes that could explain the patient’s presentation. In the case of Dr. E, we drew labs and sent her for a brain MRI. Once imaging was complete, we received a call that the patient had a brain mass that likely explained the change in personality. She was immediately transferred to the ICU and then to a tertiary care facility for neurosurgery.   

Often, doctors see patients for only a snapshot of their story and are never sure about the subsequent chapters. I had the pleasure of seeing Dr. E again at a chance meeting about a year after her surgery. She was dressed up, walking, talking, happy, and grateful for me, the surgeons, her family, and for life. 

As I reflect on my own gratitude for my training, perseverance to fully understand the patient’s story, for our paths crossing at exactly the right moment, I’m reminded of the importance of taking a good history: starting from scratch and digging deep, sometimes going down rabbit holes until the entire story makes sense, until I’m convinced that we’ve generated a comprehensive differential diagnosis with appropriate treatment options. By starting from the beginning of the story and continuing until the end, we’re more likely to provide the best treatment to our patients. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.