Beware the “Attribution Sign”

When getting a medical history, patient attribution can be very helpful.  We are even taught in medical school to specifically ask patients what they attribute their symptoms to.  For example:

Doctor: “What do you think is causing this pain in the right upper part of your abdomen?”

Patient: “It happens every time I eat a big meal, especially a fatty meal.  I think it has to do with that.”

Doctor: “This pain might be coming from your gallbladder.  We need to do an ultrasound next.”

See how easy that was? That was a helpful piece of history.  However, patient attribution can also be a dangerous thing.  Perhaps just as often as the above situation, patients can attribute serious complaints to possibly related (but in retrospect, completely unrelated) conditions.  Perhaps the most common one I get often is some version of this:

Doctor: “How long have you had this rectal bleeding?”

Patient: “Well it’s been going on for a while.  It’s from my hemorrhoids.  My buddy at work had the same thing and his doctor told him it was just hemorrhoids.”

Doctor: “It could just be from hemorrhoids, but you are 58 years old and have never had a colonoscopy, and you have a family history of colon cancer.  What if the bleeding is coming from something else?”

Patient: “Nah, I think it’s just hemorrhoids. I don’t have any pain or anything.”

It's just something I ate...I mean, I think it's just my heartburn again, or maybe it's just...(thud!)

Don’t call 911…it’s just something I ate…I mean, I think it’s just my heartburn again…wait, no it’s definitely my gallbladder acting up, or maybe it’s just…just…(THUD!)

I call this the “Attribution Sign” and once you notice this is happening it is important to remain objective about the history and not fall into the trap that the patient is (inadvertently) setting for you.  That is, don’t place too much weight on the patient’s attribution and don’t let it skew your judgement.  Keep a wide differential diagnosis open and don’t automatically start to believe that what the patient is attributing the symptoms to is the actual source of the symptoms.

In all fairness, the patients are often correct with their attribution about half the time.  The patient above with the rectal bleeding may just have a hemorrhoid.  He may say “I told you so” after his colonoscopy.  Or he may have a big polyp that needs to be removed before it turns into cancer.  He may already have cancer.  He may have all of the above.  You just don’t know until you look.

I think the combination of a few factors makes the “Attribution Sign” more common today than in the past.  First, everyone talks about health problems openly now.  People ask friends and family about sensitive health topics, where in the past many kept their own health issues to themselves.  For the record I think this openness is a good thing; however, it also opens the door to ten different people giving you their own stories, and their own “diagnosis” of your problem.  People have a funny way of putting a lot of weight into what a friend or a coworker or an aunt says, and it can be hard as a clinician to un-sow seeds that have already been planted deeply in the patient’s mind.  Second, many patients tend to google their symptoms, and already have a diagnosis or two in their head when meeting the doctor.  Sometimes they get it right, and other times they are way off.  Third, good old-fashioned denial is probably the most important factor in mis-attribution of symptoms to something benign, when the patient probably knows deep down that serious problems can also have the same symptoms.

Abdominal pain from that new medication that other doctor gave me, black tarry stool from something I ate last week, a 20-pound weight loss from a new diet I just started a week ago, chronic diarrhea from all the stress I’m under, the list can go on and on.  It’s probably just this, or that…until it’s not.  Clinicians: Keep your eyes open and beware the “Attribution Sign.”

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