Ask, and It Shall be Given You

These days, with “managed competition” and “cost control” reverberating in our ears, we must remind ourselves that the modern practice of what I call restorative medicine must often rely heavily on laboratory procedures, frequently expensive, for diagnosis and treatment. For example, experts now insist that the specific cause of Cushing syndrome can no longer be firmly established without catheterization of both petrosal sinuses, usually accompanied by measurement of the response of plasma ACTH to corticotropin-releasing hormone. Big money.

There is another less obvious but no less worrisome consequence of the emergence of laboratory data as the major determinant of the patient's status. Increasingly, data stored in the chart displace hands-on encounters between physician and patient. This departure is particularly noticeable in academic institutions where teaching rounds at the bedside may be replaced entirely by discussions in the comfort of the small conference room.

It wasn't always so. I remember a brief encounter in the past, a moment at which diagnosis and therapy hinged not on a revelation from the laboratory, but rather on the answer to a simple question.

The patient, a 60-something widow, was hospitalized for persistent polyuria and polydipsia. Her attendants were wrestling with the knotty problem of whether she was afflicted with diabetes insipidus or with psychogenic polydipsia. Studies of serum and urine osmolality, not too surprisingly, were equivocal. It was time to seek enlightenment from me, the supposed fount of endocrinologic lore. At that time, heavily engaged in academic pursuits, I was accompanied on rounds by an entourage of fellows, residents, and medical students. We made an impressive appearance at the patient's bedside, providing a psychological advantage that I had learned to exploit shamelessly. After a respectful introduction by a resident and a perfunctory interchange, I decided, for pedagogical reasons, to begin at the beginning. I asked the patient, “Why do you drink so much water?” She answered without hesitation.

“About 4 years ago, my family doctor told me to drink as much water as I could”.

I folded my arms across my chest, drew myself up to my full height (5 foot, 5 3/4 inches) and declared, “Well, I'm telling you to stop!”

“O.K.,” she said.

And she did.

• Copyright ©2004 by the American College of Physicians