The art of patient care

Renowned physician William Osler said “Listen to your patient, he is telling you the diagnosis.”  

I must admit. I often run behind schedule in my clinic. The other day, I walked into the room of the last patient of the morning and apologized for my delay. He was gracious and we began to discuss his concerns.

Turns out his health has been suffering for months, with increasing symptoms of inflammation in his nose, throat and chest. He felt like his “baseline” mild allergies-nasal congestion, post-nasal drip, and cough had increased steadily and symptoms were not resolving despite OTC meds.

The more he told his story, I sensed there was more troubling him and eventually he revealed that his wife was diagnosed with cancer and she had been through several treatments over the past year. His emotional distress and anxiety over her illness was evident but he admitted it also led to a decline in his sleep, nutrition, and physical activity levels.

Although his physical exam contained no red flags (comforting to him that we could rule out cancer and infection), we spent more time discussing the detrimental effect of chronic low-level stress on the body.

When we are faced with a situation that causes alarm, our body’s sympathetic nervous system is activated (“fight-or-flight” response), followed by activation of a cascade of hormones leading to elevated cortisol levels. Once the threat is over, these levels will return to normal (the “rest-and-digest” parasympathetic system takes over).

However, when faced with chronic daily low-level stress, those hormones remain elevated. We often see allergic rhinitis symptoms worsen.  While cortisol itself is not the culprit, other hormones like corticotropin releasing hormone (CRH) remain elevated increasing the number of mast cells and their degranulation (histamine release) making allergy symptoms worse.*

In his case, we talked through some ways to improve his stress management, return to healthy immune-supporting lifestyle habits, and reviewed some changes in medications that might be helpful in the meantime. Ultimately, I spent about 45 min in the room with him. Being able to spend that amount of time with a patient feels like a luxury, yet it’s necessary to provide well rounded effective patient care. If we had only had 10 minutes, I highly doubt we would have dug so deep to find the root of his issues.

I often run late in clinic, but I made a promise to myself that if a patient needed time to talk-I would give that time. Most patients are gracious and understand that if a day comes where they need more time, I will give it to them as well. These are the visits where trusting relationships are rooted, leading to improved patient care and outcomes in the future.  These are the visits that make healthcare more than just “sickcare”. 

* Yamanaka-Takaichi M, Mizukami Y, Sugawara K, Sunami K, Teranishi Y, Kira Y, Paus R, Tsuruta D. Stress and Nasal Allergy: Corticotropin-Releasing Hormone Stimulates Mast Cell Degranulation and Proliferation in Human Nasal Mucosa. International Journal of Molecular Sciences. 2021; 22(5):2773. https://doi.org/10.3390/ijms22052773