Four walk-in patients are waiting to see me. All four are in their 20s and report similar complaints: fever, chills, headache, and body aches. Their past medical histories are unremarkable. I ponder what malady has brought them in to be seen.
“Common things happen commonly,” I think to myself. Then I consider how the world is changing in an era of globalization. Should my differential diagnoses of “common things” be a bit different? Recent newspaper headlines ring in my head. Have these patients traveled outside the United States recently, like so many now do for work, pleasure, medical tourism, or medical missions? I read a report issued by the State Department recently that stated that more than one-third of all Americans now have a valid passport.1
The CDC estimates that up to 750,000 Americans travel abroad for medical care each year, a practice commonly called medical tourism.2 Common destinations for Americans include Thailand, Mexico, Singapore, India, Malaysia, Cuba, Brazil, Argentina, and Costa Rica.2 Increased popularity of short-term medical missions among physician assistants and other healthcare professionals also has contributed to more travel outside the United States. These short-term medical missions have increased access to healthcare services in medically underserved areas all over the world, and offer unique appeal to American healthcare professionals who enjoy the adventure of travel, exposure to new cultures, and engagement in patient care services for individuals in need. Some of these missions are large and well recognized, such as Mercy Ships, Project Hope, and Operation Smile, but most are grassroots efforts sponsored by churches, small philanthropic organizations, universities, and medical societies.3
I am thankful to be part of an educational model that repeatedly teaches students that taking a patient's history is the most important skill in medicine. However, even after practicing for more than 25 years, I still have to remind myself not to forget the basics—immunization history, travel history, recreational activities—and simply focus on a history of the present illness. I answer questions that the electronic medical record asks; time often precludes me from gathering information outside the prompts, such as which community activities my patient participates in or what my patient does for fun on the weekends. The recent Ebola outbreak has turned our attention toward the less common, even rare illnesses that a good medical history might uncover.
Returning to our four patients, we discover that the 27-year-old man recently traveled to Puerto Rico for his honeymoon. Have we included dengue fever in our differential? The 2007 epidemic of dengue fever affected more than 10,000 patients in Puerto Rico, the US Virgin Islands, Samoa, and Guam.
Our next patient, a 26-year-old woman, traveled to the Caribbean for business. Have we included chikungunya in our differential? Nearly 700 cases of chikungunya virus in the United States were reported to ArboNET, the CDC's national surveillance system for arboviral diseases, as of late August 2014.
Our third patient, a 22-year-old woman without health insurance, traveled to Southeast Asia for breast augmentation surgery. Have we considered Middle East Respiratory Syndrome-Coronavirus (MERS-CoV)? MERS-CoV has a monstrously high 40% fatality rate (SARS was about 10%). The World Health Organization reports that 75% of MERS-CoV cases may be from close human-to-human contact.
Our fourth and final patient is a 21-year-old student who just returned from a medical mission trip in Ethiopia. You try to remember if this African nation is one of the countries affected by the Ebola outbreak.
I ask myself, “If it walks like a duck and quacks like a duck, is it a duck?” As PAs, we have to stay connected to the global burden of illness. In an increasingly interconnected world, we can leverage powerful databases and electronic search engines to help us quickly access the latest information on disease outbreaks and clinical presentations that can expand our differential diagnosis list. We then must exercise precision and rigor in assessing patients' history and physical examination. The recent cases of Ebola, and the gaps and potentially harmful delays in connecting the initial patient's history and disease in Texas, are powerful reminders to all of us.
1. Bender A. Record number of Americans now hold passports. Forbes
. January 03, 2012. http://www.forbes.com/sites/andrewbender/2012/01/30/record-number-of-americans-now-hold-passports
. Accessed October 7, 2014.
2. Centers for Disease Control and Prevention. http://www.cdc.gov/Features/MedicalTourism/
3. Maki J, Qualls M, White B, et al. Health impact assessment and short-term medical missions: a methods study to evaluate quality of care. BMC Health Serv Res