In my early years I supplemented my income by doing locums in rural areas, filling in for the local doctor. A locum is a temporary fixture, not part of the community, and consequently not acquainted with its customs. For a city boy this would be a daunting experience; country folk describe their health and medical problems in a manner that often leaves the listener baffled. Fortunately, I was born and raised in rural Manitoba and the discourse of country people was second nature to me. The key is to understand their main obsession – which is to give nothing away. Only essential information is revealed, and that grudgingly. They control the information flow so that the doctor, or anyone else listening, hears only what they want him to hear.
The location of this encounter is of no importance; it could have been anywhere west of Winkler to the Saskatchewan border. My first patient that morning was Mr. Alvin Jones, age fifty, a farmer. The file handed me by the receptionist was blank; this was his first clinic visit. Mr. Jones is, of course, a fictional name. He entered the examining room hesitantly, politely removed his John Deere cap, and waited until I motioned him to a chair. If you know where the John Deere Implement Company has the largest dealership in rural Manitoba you will have identified the town.
I believe in the adage that first impressions count, so I prepared carefully for locums – newly starched lab coat, name tag, white shirt and tie, fresh haircut. He was also dressed for the occasion (probably by his wife): clean shirt, dress shoes and a new cap. From my vantage point behind the desk I could sense that he was uncomfortable. He didn’t look at me directly but glanced about as if looking for an escape route.
But time was pressing and there were already a dozen patients in the waiting room. I started briskly. “Good morning Mr. Jones. I’m Dr. Tweed and it seems this is your first visit to this clinic.”
“I guess so. Where is the old doc, Dr. Petkau?”
I explained to him that Dr. Petkau was attending a refresher course, and then taking some vacation, and I was his substitute for two weeks. This established, I was ready to get down to business. With a new patient it is generally useful to get some information about past medical problems, so I like to start with a brief medical and surgical history.
“Right, Mr. Jones. Have you ever been sick in the past or had any surgical operations?”
“Yeh, once in a while.”
“And what sort of sickness have you had?”
“Oh, the usual things.”
“Now, by the usual things, what exactly do you mean?”
Hesitation. “Oh, the sort of things kids get.”
“You mean you’ve had the usual childhood diseases: mumps, measles, chicken pox?’
“Yeh, I guess so.”
“Right, Mr. Jones and what brought you here this morning?”
“Oh, my wife drove me.”
“Well, yes Mr. Jones, I’m happy to hear that. What I really meant was what did you want to talk to me about?”
“Ah! I came in to ask you about a little problem I have.”
“Oh, and could you describe this problem?’
“Yeh! I guess I could.” There followed a long pause during which he gazed at the ceiling as if seeking divine inspiration. I grew impatient.
“Yes, and if you were to describe it, what would you say?”
“Well, I ain’t feeling very good.”
“Not feeling good, and how long have you not been feeling good?”
“Oh, quite some time.”
Would you say days, weeks, months?’
“Yeh, something like that.”
We were now about five minutes into the medical history, on a busy clinic day, and I had learned almost nothing about Mr. Jones or why he was here. Either he was especially obtuse, or remarkably stupid, or he was hiding something. Perhaps he had a medical issue or concern that he was afraid to mention, something he hoped I would guess without his having to admit to its reality. Or, as an afterthought, perhaps he was testing me. It is a notion held by some country folk that, if the doctor is so smart, especially a young doctor, he should be able to figure out what’s wrong with you – you shouldn’t have to tell him. It was time for the more tedious but reliable method of direct questioning.
“Now, Mr. Jones I am going to ask you some specific questions about your current health. I just want you to answer yes or no. First, do you have any pain?”
“No, not right now.”
“Was it because of a pain that you came to see me this morning?”
“Was it because of a sexual problem?”
The list could go on, but would continue until I got a yes.
“Is it because you are feeling weak or tired?”
“Yeh. That’s it. I can hardly walk to the barn before I get tired.”
We were now about ten minutes into the medical history and starting to make some progress. His chief complaint, with which we usually begin a medical history, was fatigue. In a fifty year-old man there are many causes for fatigue, but at this pace further history taking was a poor investment of my time. Next step was a physical examination and some basic lab tests. The physical examination showed nothing abnormal, the lab tests were scheduled, and I advised him to come back next week.
Next week he was a little more talkative, either because he had tested me enough or because he was more worried.
“Good morning, Mr. Jones. How are you today?”
“Oh, about the same.”
“Are you still feeling tired when you walk to the barn?”
He looked hopeful, but my news was not good. His laboratory tests were unremarkable, except for one. He was seriously anemic – his hemoglobin level was much below normal. Fatigue and anemia in a man his age was probably due to chronic internal blood loss. The most likely site was the large bowel.
“Mr. Jones, I have to do a rectal examination. That means I put a finger in your rectum to feel around. But first tell me, has there been any change in your bowel movements?”
His response was immediate; he didn’t have to look at the ceiling for inspiration or concoct a vague rejoinder. This had obviously troubled him but the color of one’s shit is a private issue, not a medical problem. How could there possibly be any relation between black shit and feeling tired?
“Yeh, I’ve had some black looking movements in the last couple of months. Does that mean anything?”
The rectal examination did not reveal a tumor within reach of my index finger, but his stool was black and the guaiac test, the test for occult blood, was positive. Whether the growth in his large bowel, the cause of his anemia, was or was not malignant could not be determined at this stage. He needed a surgical consultation, a biopsy and probably a bowel resection. I had done all that I could do.
Once all his cards were on the table and the bad news was out Mr. Jones was a different man. He seemed relieved of his burden and wanted to move ahead. Harvest was coming up; but how would he manage? Should he keep his son home from college? Who would reasonably expect a modern 18 year-old to obligingly miss a year of college to help on the farm? College life is much more rewarding, and exciting, than life on the farm. What should he tell his wife? If he delayed the operation until winter would he recover in time for spring seeding? Seeding and harvesting were the milestones in a farmer’s year, everything else took second place.
Of course, I had no answers to these questions, but discussing them seemed to take priority over his immediate treatment. We parted on amicable terms and I never saw him again.
His candidness in the face of reality was in striking contrast to the evasiveness of our first interview. Why are some people so vague and find it so difficult to discuss their medical problems? Perhaps they simply lack the vocabulary; just as some lack a vocabulary for sexual discussions – except for one universal descriptor of course.
Perhaps they fear the answer or are testing their doctor to judge whether he merits their trust. But I believe that it is more likely a product of the natural reticence of country people. In a small, gossipy community privacy and confidential information are carefully guarded. One doesn’t air his private affairs in public, no matter how long he has known his neighbours. They may know all your secrets, but they will never admit that to your face. You don’t boast about your bank balance, or spend money ostentatiously. You never discuss intimate topics, except in the privacy of your bedroom. And you don’t disclose your medical details to a stranger, even if he is a doctor. And certainly not if he is a smart-ass young doctor just out of medical school.
Technical notes: The guaiac fecal occult blood test (gFOBT) is one of two simple tests for occult (hidden) blood in the stool, blood that is not visible on the surface (the newer test is the fecal immunochemical test (FIT)). Guaiac paper for the test is prepared from the wood resin of Guaiacum trees, a tropical tree commonly known as lignum-vitae. In addition to its lumber and ornamental values this tree has found several medicinal uses, now only of historical interest. Gum from the wood was used to treat syphilis in the 16th to 18th C, as well as arthritis and cough (guaifenesin). The latter may still be found in some cough preparations.
Black, tarry stool indicates serious bleeding higher in the gastro-intestinal tract. Both the gFOBT and flexible colonoscopy are recommended as screening tests for bowel cancer in the 50-75 year age group. There are arguments pro and con for each, but the gFOBT is simple, non-invasive, inexpensive, requires no anesthesia, and can even be done at home. In 2006 the NHS in the UK introduced a bowel cancer screening program using gFOBT. They reported that it was associated with a 15% reduction in mortality (Koo, Neilson et al. 2017). The gFOBT will soon likely be medical history only, replaced by the more sensitive FIT test.
Koo, S., L. J. Neilson, C. Von Wagner and C. J. Rees (2017). “The NHS Bowel Cancer Screening Program: current perspectives on strategies for improvement.” Risk Manag Healthc Policy 10: 177-187.