The man nodded and I asked the first question, “Can you dress yourself?” I gave the man the choice of no difficulty, some difficulty, much difficulty, or unable to do.
“No difficulty,” he answered right away. I hit the little button with a sharp jab.
I then asked the next question, “Can you shampoo your hair?” I was staring at the computer screen of my handheld gizmo, ready to push one of the little buttons. I realized 20 questions was a lot and that time was passing.
There was a long pause and the patient was silent. I was surprised by the delay since the answer should not have been hard. My finger was itchy. I was ready to go on.
“I don’t know how to answer this question, Doc.” The patient said and I looked at his face. His mouth had narrowed and he had a querulous expression.
I was about to repeat the question when I finally registered the appearance of the man’s head. He was totally bald. There was not a hair in sight. His scalp—smooth as a billiard ball—shined brilliantly in the harsh white light of the examining room.
It was clear that, in fixating on the man’s hands, I hadn’t paid attention to the rest of him, missing the most obvious feature of his appearance.
I was deflated and embarrassed and mumbled something like, “You know what I mean. If you wash your head, do you have trouble?”
“No,” he said, his word clipped.
I plowed through rest of the questions and let the calculator do its magic. As it turned out, the man’s HAQ was actually low, his perception of his functioning in fact worse than the reality. After explaining the alternatives to the man, he decided to stay on just methotrexate alone.
After the visit was over, the house officer expressed appreciation for the teaching and admiration for rheumatology’s focus on the patient’s life. I doubt these feelings are sufficient for this fine chap, destined for a life swathed in lead, to reconsider his career path. How could 20 questions match the sophistication of giant machines that create images of surpassing clarity with showers of X-rays and magnetic atomic flips?
Lessons Learned
While I feel chastened by my first use of the HAQ, I am not deterred. I have learned old lessons and some new ones. First lesson: Keep your eye on the ball. Look at the whole patient. Computer screens are fine but they are no substitute for the old standbys built on the senses: inspection, palpation, and auscultation. Olfaction is another one. I once had an attending who insisted we smell the patient’s breath so we could pick up the telltale scents of uremia and infection. Having smelled terrible things emanating from the mouths of patients, I don’t recommend this approach even if it occasionally gives a nifty clue for diagnosis.