Resistance in the materials vii

If anything has happened there will be traces of it. Lies cannot stand up against the truth, because there are a million lies that can sound convincing, but there is only one truth. You can pile them up as high as you want, but eventually they all come toppling down if you continue to test, if you scrutinize, if you are meticulous, if you are tireless, unwavering, wholehearted in your pursuit of the truth. In this world of grays, spectrums and continuum, this is a blessed discretion. A true binary. You see, something can either be true, or false, but not both. Either something happened, or it didn't. Both statements cannot be true. This is the beauty of logic. Its precision. Its indisputibleness, its unequivocality. Either it happened or it didn't happen, and if it happened, there will be evidence. There will be events leading up to it, events that caused it, circumstances that allowed it, witnesses to the event, and events resulting from it. DNA. CCTV footage. A body.

But what about the body. What about rates of change too fast, or changes too minute for us to register? What about a cold, or a virus. They are self-limiting, they disappear as quickly as the body renews its cells. All evidence lost. All matter disintegrated, recycled, disposed of.

Not true. Antibody titres. They proliferate and remain increased following exposure to an antigen. Acute phase reactants. Post viral wheeze and mesenteric adenitis. Patient's general malaise. They remember because that day they felt poorly and couldn't go to the gym, or forgot to make that important phone call or stayed home from work. Anything that happens, even on a microscopic scale, leaves its mark. There is always evidence if you look hard enough. If you look close enough. If you look wide enough. But it's time sensitive. The longer you wait the more confounding variables there are to account for. That's what it means when the case goes cold.

History is simply the forensic science of human and natural events.

There are many versions of the truth. The certain thing is the evidence. You can use those points, connect those dots to paint many different pictures, but in all my years of experience, you never ever ever get just one.

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'that's where wise as serpents comes in'

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"How can I help you today?" "Well, there are a couple of things..." she says and then pauses. 'That's fine,' you say and grab a pen to write them down. You appreciate the warning, it allows you to apportion the time appropriately. The first two are trivial, 3 week history of back pain right side and in the spine worse on movement. The next also sounds like a trifle, a 3 week history of non productive cough, occurs throughout the day, worse when she lies down.

"And was there anything else?" She pauses again, longer this time.
"Menopause."
You try not to look flustered, racking your brain to remember the indications for HRT and what questions you need to ask.

You decide to leave that till the end and if there isn't enough time you can ask her to book in again. You start with the two and try to get through them relatively quickly. "Just here?" "Yes- ouch" You prod her back and tell her it should improve with ibuprofen. "Nothing to hear on the chest." It transpires she's had a cough before and heartburn in the past. You prescribe her 4 weeks of lansoprazole.

"So, what problems are you struggling with?" The woman struggling with concentration and memory, saying it was alzheimer's. Put it down to menopause, lmp 5 years ago. Tiredness, irritable since beginning of the year. More you ask, she's felt down, father died in May in hospital. Feeling hopeless, more recently suicidal. Daughter has told her to come to the doctor's. And she leads with back pain, ooh and this cough for 5 months, the last thing she mentions is her memory and... just difficulty concentrating in conversation. Walking into a room and forgetting why. Maybe if you hadn't asked she wouldn't have mentioned it at all. Maybe if you had asked a different way she wouldn't have told you, if you hadn't introduced yourself. The older folk, my mom's age they know what's wrong but don't want to say it. They want you to say it, because they want it to be something other than depression. Because depression means weakness, a lack of resilience, that you are less developed, less well-adjusted, less fortunate than your colleagues and friends.

You made a difference that day, you tell yourself. You picked up on something and possibly changed the course of the next day for them, the next few months, the next few years. Or she would have come back the next week, seen someone else and been diagnosed then. Who knows.

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People react differently under stress. They react differently based on how you phrase the question. The order of questions is also important. What you get to decide is how much and what kind of information you disclose to the suspect. It's not the questions that gets them talking, it's how you agitate them psychologically that gets their mind churning and their mouth open. If you can get them talking and keep them talking, you've won. Ten times out of ten, in trying to defend or absolve themselves they end up incriminating themselves instead.

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misleading history // fake news // the customer is not always right

Pain behind eyes, he says, with headache, with weakness and paraesthesia, with cough - a whole constellation of symptoms that fail to form any discernible picture.

You spend an hour on him, testing every system - looking at the retina, trying to elicit reflexes.

You don't even once think to doubt his testimony.

So you go with a handful of signs and symptoms that don't add up wondering what miraculous diagnosis will tie them all together, and the GP scrolls through his notes and says, 'Ah yes, he's got quite a lot of mental health issues, doesn't he?'

And it dawns on you that all the symptoms were really just one symptom: anxiety.

How to not over-investigate everybody. Not to chase every painful ear and runny nose and belching fit hoping it will lead to a neat solution. How to know when to regard what the patient says with a pinch of salt without writing off every instance of central crushing chest pain as indigestion. How do they do it? They likely accumulate a wealth of experience and let that guide them, learning from trial and error to hone their 6th sense, to refine their skepticism and have a high index of suspicion for when things aren't quite making sense. How to become a wielder of Occam's razor. In hindsight, it's apparent that the simplest explanation was anxiety and hence the most likely. It's easy to fall in love with a hypothesis, to become biased so that you change the facts to fit the story. But no, you shouldn't let the conclusion lead, you let the evidence point you to the conclusion. But at the same time, while assessing you must consider all possible conclusions, all scenarios that could account for the evidence. You can't cherry pick your data. Can't choose to include one piece of evidence and disregard another.

And so you become hesitant to ask certain questions, to do a systems review, because sometimes more information isn't helpful but harmful to the investigation. You must pick questions with discriminating power, ones that will either help strengthen a hypothesis or help you discount one. And yet you know you really should do a system's review. Because what you think is probably a red herring might turn out to be a red flag. And the patient might not even care that he can't see out of his right eye since yesterday since his sciatica has been flaring up again - but you should care. You're supposed to care.

How do you know when not to trust what the patient says? Does the drug addict really have intractable neuropathic pain? What are the odds? The doctor's job is to come running any time someone cries wolf - but also to be able to recognise a wolf from a Labrador, and maybe even teach patients how to recognise one.

So what are the odds that this gentleman with traumatic stress disorder, pain behind the eyes and two episodes of slurred speech has a TIA? You know he isn't lying to you. He truly does believe he experiences all that he relates to you. And I suppose the answer is: you have to believe him as well, but all the while keeping in mind that while patients are experts when it comes to their illness, even experts can be wrong sometimes.