Moving Beyond “Boxed-in Thinking”: Imagining a Problem from the Patient’s Perspective

By Manveen Saluja

A number of years ago a woman in about 50 year old presented to my office complaining of “walking on a vein” in her left foot. She reported having seen a number of physicians – 9 in total – with no successful resolution.  She was told that there is no vein that could possibly roll under her foot, and her complaint was dismissed.

Her past medical history was significant only for a healed fracture in her left foot that occurred 9 years ago.  She believes the sequela to the fracture is that “a vein rolls under her foot” as she walks. She does not experience pain in the foot, but she is very distressed because she can’t walk or dance as she could before the fracture.  As I talk with her, I realize she has been experiencing this unpleasant sensation every time she walks for 9 years…

The physicians she has seen in the past have completed a thorough and robust workup.  She has had an orthopedic evaluation, radiographs, and subsequent appointments with podiatrists.  All of the evaluations have revealed that there is no abnormality.

Finally, she was referred to rheumatology, where I met her.  A simple physical examination of her left foot revealed a subluxation of the fourth metatarsal.

Looking at it in another way, from the patient’s experience and her lack of anatomical knowledge, I realized that walking on the subluxed joint could give her – or anyone that doesn’t have medical knowledge – the perception that the metatarsal head is a “vein” that rolls as she walks.

I gave her a metatarsal pad insert to alleviate the pressure on the head of the metatarsal joint and allow for better alignment of the joint while walking.

When she returned for a follow-up appointment in a few weeks, I was surprised to walk in the exam room and receive an enthusiastic hug from a woman wearing high-heeled shoes.  She profusely thanked me for curing her condition, and excitedly told me about all the dancing she has done in the last week.  “I haven’t been able to dance for years!” she gushes.

She was discharged from my care and I have not seen her since then.

I have often thought of this case, because in my experience, it provides an important example of a simple diagnosis that was missed because of what I would call “boxed-in” thinking.  This all too common pattern of thinking by physicians to recognize a diagnosis by certain description only doesn’t allow for the presenting symptoms to be completely evaluated and leads to misdiagnosis or not needed diagnostic tests.

Therefore, patients that are not knowledgeable about anatomy, physiology or disease process, are non-native English speakers, or don’t express themselves in a typical fashion are too often dismissed simply because physicians training is to recognize disease through book described symptoms.

As such, I suggest that we use “open mind” thinking when a patient describes his or her symptoms.  In this case, the patient was describing the sensation of walking on a vein when in fact she was walking on the subluxed metatarsal head.  Her barrier to understanding anatomy and medical jargon, while completely understandable, led to unnecessary procedures, specialist visits, health care bills, and long-term suffering because nobody took the additional step to interpret what she was trying to express.

Medical students, residents and physicians must be trained to realize that patients do not consistently present with “buzz words” that are pathognomonic or even suggestive of a diagnosis.

Although is good to know “buzz words”, a physician can help patients by listening with an expanded perception and an open mind. As illustrated in this case, radiographs couldn’t diagnose a 3-dimensional issue with a 2-dimensional image.

In many cases, the simple action of thinking from the patient’s perspective can help us become better physicians.

saluja-b
Manveen Saluja, MD, FACP
, is a Board Certified Rheumatologist and Clinical Associate Professor at Wayne State University and
Assistant Professor Oakland University William Beaumont School of Medicine.

One thought on “Moving Beyond “Boxed-in Thinking”: Imagining a Problem from the Patient’s Perspective

  1. Thank you Dr. Saluja for this valuable reminder. Critical reflection can indeed help prevent cognitive error/bias. And being intentionally present to, in your words, “help patients by listening with an expanded perception and an open mind.” The title of a relevant article “From Mindless to Mindful Practice” http://www.nejm.org/doi/full/10.1056/NEJMp1303712 (Croskerry, 2013) resonates for me with your keen observations and message. How reassuring to know there are mindfully present, critically reflective, and open-minded healthcare practitioners like you out there!

    Liked by 1 person

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