"All right, have a crack at this guy," said the doctor.
It had been a fairly monotonous day albeit busy. Coughing, sneezing, sore throat - these three symptoms covered all that I had seen that winter morning.
I took a look at the thin 28-year old man sitting at the vitals station. Buzzcut and beard trimmed, the man dressed in black from head to toe. His jacket gave away that he worked with law enforcement, but he had no bright, shiny badge to boast of it.
One of the nurses pulled me to the side and said, "Be careful with this one. He does not want to go in a room." I collected myself before approaching the man.
"Hello sir," I said as I proceeded to introduce myself as the medical student working with the doctor this week. "Do you mind if I talk to you?"
"No, fire away."
"Alright, what brings you in today?"
"I just feel like killing people."
When we first learn how to conduct the medical interview, we learn to ask questions pertinent to the patient's complaint. When we hear "chest pain," we should ask about exertional dyspnea (stable angina), chronic heart burn (GERD), and even medication history (pill esophagitis). The complaint opens up a triage of possibilities that in turn help to pinpoint the diagnosis.
Suicidal ideation, though, required me to think on my feet, and I had to treat the complaint as seriously as it sounded. In retrospect, my first thought, "Seriously, you’re kidding right?" seemed highly inappropriate, especially with the tragic school shooting in Connecticut only a few days earlier, but something seemed amiss. His countenance reflected the gravity of what he told me, but his eyes burned in a different light as though alive with mischief.
What moves the medical interview from a script to a skill lies in the integration of these non-verbal cues. These cues in turn help to cull the diagnostic possibilities opened up by the initial line of questioning.
This subtle aspect of the interview reminded me of a common misunderstanding surrounding the Hindu concept of karma (action). Karma accrued by a Hindu translates to the fruits - sweet or sour - that he or she reaps in this life as well the lives that follow. Hindus believe that when they die, their atma (soul) transmigrates from one body to another, and the aim of their faith lies in gaining moksh--literally “freeing oneself of pain"--by escaping from this cycle of birth and death. Until a devotee exhausts his or her stock of karma, they remain bound to the endless cycle.
As simple as it sounds, karma cannot be exhausted quite so easily. The mere act of blinking an eye or conjuring up a thought in and of itself constitutes karma. However, when an action is paired with the idea of pleasing God, this act becomes a form of bhakti (devotion) and thus counts for nothing. For a Hindu, reiterating their purpose helps them strengthen their understanding and attain moksh.
One Sanskrit aphorism found in the Upanishads, a set of commentaries written on the Vedas which are the central scriptures of Hinduism, illustrates this idea through the metaphor of two men--one blind and one lame--who can accomplish together that which either could not do alone. Karma equates with blindness, for action can be performed without regard of the fruits borne of it. But only when combined with knowledge, lame by nature, can karma be directed towards a higher purpose - bhakti. Knowledge by itself cannot accomplish anything.
The noble purpose of medicine calls upon us to serve our patients. We cannot simply hand off the knowledge we have gained and hope that they treat themselves alone. Lame by nature, our understanding of the patient’s story and their body language guides our questioning which would otherwise be rendered blind.
Recognizing the mismatch between my patient's eyes and his facial expression, I decided that I needed to hone in on a hidden motive. I had to see if his details matched with his complaint.
Okay, start by acknowledging..
"How long have you had these feelings?"
"For about a month."
That’s a long time for someone to harboring such thoughts while also having easy access to a firearm. I wonder how he copes.
"I see. How do you deal with these feelings?"
"Drinking and pills."
Substance abuse - get more details.
"How much do you drink?"
"Like a sixth of one bottle of liquor daily."
"And what kind of pills?"
"You know, painkillers like Percocet. I usually just snort them because they work faster that way."
The details thus far fit with his suicidal thinking, I mused while we sat in the vitals station with nurses walking by pretending not to pay attention. But before I could ask another question, the doctor showed up and said, "I will take it from here. Go see this other patient." She was here for a follow-up visit to refill her medications. It was less complex than my first encounter, and naturally my mind still lingered with the first man.
After some time, the doctor came back up to the front and sent off the prescriptions to the pharmacy.
"Is he alright?" I ventured to ask.
"Yeah, he was just joking with you."
No kidding, I thought. "You know what? I could not help but feel that way from the get-go."
"Yeah, but you should have seen the number he ran on the girl before you."
I felt slightly dismayed that I did not get the chance to arrive at the true conclusion myself, but this encounter reaffirmed to me that the skill of medical interviewing required a keen awareness of non-verbal cues and not just questions alone. Inquiry bereft of insight could not hope to accomplish much in the way of patient care.