Lexi!
A plain X-ray film appeared on the computer screen—a humerus, a radius and an ulna were all visible. My pupils zoomed around the screen, and on initial inspection, everything looked fine. However, this X-ray was unlike any film I had ever reviewed. You see, it was for my then 4-year-old puppy, Lexi.
My sweet little clown pup had begun to limp on her right front leg. It didn’t seem to bother her too badly but its persistence over four weeks made me very concerned about what was going on. And, like any rheumatologist would, I wondered if my dog could have inflammatory arthritis.
Questions, Questions!
Soon thereafter, a veterinary technician came to get us for intake. The very familiar preparatory rituals of a clinic visit were taking place. The technician coaxed Lexi onto a scale to assess her weight and then brought her to a room so I could complete a general questionnaire. She handed me a clipboard with four pages, full of detailed questions that started with “Preferred name of domestic animal” going all the way down to a list of “prior surgeries without anaesthetic.” Particularly bothersome were impenetrable columns of checkboxes, which I suppose were meant to assist in quickly gathering data but just seemed repetitive. Somewhere in the middle of the second page, I noticed that I had started to pay less attention to the questions and more to the act of drawing X’s. Complicating the process were ambiguous questions that seemed to apply to different animals, like “the ability to ruminate.”
This exercise brought me back to our clinics, where our own questionnaires for disease activity are often filled with similar matrices of checkboxes, albeit a little less in scope. I started thinking: In the well-meaning desire to incorporate patient-reported outcomes, our clinics may be losing sight of the holistic nature of what it is to have a healthcare issue. Moreover, I felt like I wasn’t particularly in the right headspace to answer so many questions in an objective manner. Not only was I keeping a close eye on Lexi to make sure she wasn’t getting into trouble, but I was also juggling a sense of uncertainty and imagining the worst. I started doubting whether the clinic would even listen to my concerns in favor of collecting more and more data.
Social History 1st
Humans & dogs are social animals, so social history should come first.
After a few minutes—and a few doggie treats that calmed down little Lexi, the veterinarian—let’s call her Dr. N—entered the room. She said a few words to say hello and got straight to work looking at the chart in the computer and the questionnaire. I was struck by the quick pace of everything before she turned around to me and began asking me the customary questions. To tell you the truth, I was skeptical—would she go over the same things that I had just answered on the questionnaire?
No, Dr. N was wiser than that. She started with, “How’s Stella doing?” Stella is our older pup, who, at that time, was around 6 years old. At first I thought it was a rapport-building question. Certainly the patient experience consultants who periodically come around to our clinics encourage us to ask questions like that to improve the clinic’s patient satisfaction numbers.
But she didn’t take “fine” as an answer. She dug in deeply: Does Stella have a limp? How does Stella play with Lexi? And so forth. It wasn’t just a pleasantry for patient satisfaction. Dr. N was very subtly taking a history while putting me at ease. Then she asked us about our kids and how Lexi interacts with the kids. Here, Dr. N wasn’t getting a social history for the sake of billing but was trying to put together a richer, more detailed picture of whether some external force had prompted Lexi’s limp.
That was something new to me. In medical school and throughout postgraduate training, the typical structure of a clinic visit starts with a golden minute of small talk, followed by a direct inquiry into the chief complaint. Social history and other elements are expected to come later—but Dr. N flipped this entirely. She segued the golden minute into the social history and used that as the basis for understanding the chief complaint.
While I can’t imagine doing this on a first clinical consultation visit, I can surely imagine doing it on routine follow-ups. It makes complete sense to me to start off with how chronic diseases that involve lifestyles and social relationships impact patients’ social lives and how their social lives impact their disease activity.
The History
Only after getting the social history did Dr. N solicit the chief concern and inquire about the review of systems. This, I was pleasantly surprised, was pretty much the same as an encounter in the rheumatology clinic. She asked the five elements of pain (i.e., location, severity, duration, associated symptoms and modifying factors) and seemed to go from head to toe, probing for any further context. Yet there was an important difference between how she performed the review of systems and how I would in my clinic.
Maybe it was because of her own personal experiences of taking nebulous histories from pet owners, but she seemed to revisit the chief concern after every system reviewed. For example, after confirming that Lexi didn’t have any changes in stool, she explained that parasitic disease can cause musculoskeletal complaints. So she went back to my description of Lexi’s limp and asked about any preceding gastrointestinal illnesses. Throughout this reinforcement, she kept asking me if the story was being adequately represented—something that I appreciated. At the same time, she was looking carefully at the questionnaire to methodically ascertain if what I was saying matched what I had written earlier. In fact, she even marked a few questions with more details that I relayed in the conversation.
This approach took some extra time, but it made sense. Dr. N wasn’t only gaining information to resolve a clinical dilemma but she was activating me, prompting me to make connections between the symptoms I was relaying with the chief concern. In the process, she was also educating me about what to expect, empathizing with me about Lexi’s problems and prompting me to consider alternative explanations.
I can understand how this may not necessarily be applicable to many (if not most) cases in a busy rheumatology clinic, but in unclear cases where the history isn’t making much sense, I can distinctly see its value.
Close Observation
I’ve always been an aficionado of the physical examination, so I was particularly intrigued by how Dr. N would approach Lexi’s physical examination. Dr. N was pretty perceptive, so I imagine that at this point, she realized she was talking with someone familiar with medicine and healthcare. Certainly, I couldn’t hide the degree of interest I took in seeing her physical examination maneuvers. In fact, it brought me back to my medical school days in which I would very carefully observe an attending for every movement, like it was a magic show.
Dr. N called Lexi and put her collar back on. Then she asked me if I was willing to take a brief walk outside. It was refreshing to leave the clinic and go into the fresh air and sunshine. As I walked Lexi down the sidewalk, Dr. N squatted on the ground and trained her eyes on Lexi’s gait. First, she examined Lexi’s hind legs and then asked me to turn Lexi around so she could focus on her front legs. Dr. N then rubbed the palms of her hands together to warm them and placed them on Lexi’s right foreleg.
What she did was a mirror image of what I teach my trainees for the elbow exam. She first inspected the area for any skin changes, scratches or other signs of injury. Then she lightly palpated the joint, taking great care to observe Lexi’s reactions when pressing on her joint. She examined the other front leg, comparing one to the other, carefully trying to find any swelling or tenderness. And then, lastly, she gingerly placed her thumb and fingers on opposite sides of the elbow and assessed for range of motion.
All the while, she was talking out loud and explaining what she was seeing, feeling and thinking. It struck me that, at least among vertebrates, the principles of the physical examination are pretty much the same—functional testing in situations most closely resembling real-life conditions, close observation with every maneuver, comparison of active vs. passive range of motion and contrasting affected joints against unaffected ones.
Keep Patients in the Driver’s Seat (with the Windows Down)
At that point, Dr. N turned to me and explained that an X-ray was probably necessary. Lexi was whisked to the back, and within a few minutes, that plain X-ray was placed on the screen. What’s notable here is that the time I was in the room without Lexi wasn’t seen as idle. As a veterinary tech had come to take Lexi away, I was handed a shiny brochure explaining canine arthritis. The brochure had the right balance between being comprehensive and comprehensible. Everything was laid out at probably a fifth grade reading level with lots of diagrams. It certainly kept me occupied as I waited for Lexi to return.
Thankfully, the radiographs were within normal limits. Perhaps a bit of soft tissue swelling was present but there were no structural defects. But what was surprising was that Dr. N didn’t downplay the normalness of the X-rays. She actually preempted the discussion by mentioning that radiographic changes of canine arthritis can be delayed and that the absence of significant findings doesn’t take away from Lexi’s apparent symptoms. That validation was a tiny thing, but an important step. I noticed that my palms were slightly sweaty; even though I didn’t feel very stressed, certainly I was in a fight-or-flight response. Having my unspoken concerns validated was comforting.
In the end, the encounter was mostly reassuring—perhaps a self-limited ligamental issue was at the root of Lexi’s distress. Dr. N offered a CT scan and a referral to a specialist—but not having pet insurance, I deferred. (I choked back the temptation to nervously utter a corny dad joke about CAT scans on dogs, but anyway.) All the while, I realized we were engaging in shared decision making. Dr. N was probing my interest in various options and was even-handed without framing things in a way that was coercive.
Happy Dog; Happier Doctor
Watchful waiting and some doggie meloxicam were the main outcomes of this visit. Even though, on the face of it, there were very few actionable items, something important transpired. I felt a sense of relief that I was listened to and that someone competent was paying close attention to my concerns. I also felt a sense of gratitude that I could trust this particular veterinarian moving forward. After all, watchful waiting doesn’t mean wishful waiting—a follow-up, whether formal in the clinic or on the phone, would still be necessary.
Lexi came home and had lots of doggie treats. We took nice slow walks for a few weeks, and her limp eventually resolved by itself. I’m not sure exactly what that was about but it looks like Lexi isn’t any worse for wear. One year onward, she’s a happy middle-aged puppy that eagerly looks forward to walks. I do keep an eye on her front leg, but except for the most subtle apparent stiffness when first getting up, everything seems good.
The entire experience has made me grow as a rheumatologist. When I returned to the clinic the next day, I realized that I was imitating some of the things that Dr. N had done: I was more cognizant that I needed to communicate in a clear fashion and be more attentive to the emotional needs of patients and their family members. Thanks to this visit to the vet, I felt more appreciative of my role as a rheumatologist in not just providing relief for pain and inflammation, but also relief from uncertainty and isolation.
Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the associate program director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on Twitter @BharatKumarMD.
