How I Learned about Incontinence

And what it says about learning in medicine

TR was an 86-year-old man who presented to our Urgent Care with back pain three weeks after a fall. He had slipped as he was getting up from a table at his favorite coffee shop, a place he goes every day to meet with “some of my old fogies.” His chronic back pain, which usually runs at about 3/10, had gone up to about 7/10 after the fall. Things have been slowly getting better. There were no associated symptoms. The exam that my intern performed was normal.

To my intern’s annoyance, I focused on the patient’s urinary function. The room clearly smelled of urine, and I was unsatisfied with his assurance that the back pain was mild and improving and that the patient said he noted no perineal numbness. I insisted on a sensory exam of this area.

It was normal.

There are two truths to learning medicine. The first is that learning must never stop. It is impossible to master the field during medical school and 3 to 10 years of postgraduate training. There is too much information, and the diagnostics, therapeutics, and prognoses are always changing.

The second truth is that we learn best from our patients. During the years that I directed the Internal Medicine Clerkship, I encouraged students to read about the diseases their patients had. My quarterly orientation spiel was:

I still remember everything I learned about cirrhosis when I was in medical school because I associate the information with a patient. I picture JR, whom I cared for during my 3^rd year clerkship. Every day I tapped his belly to drain his ascites, every night I learned more about the disease process.

In contrast, I can’t remember what I read in the New England Journal last week.

One of the consequences of these truths is that I remember who — patients, teachers, colleagues — taught me everything I’ve learned.

During my internship, I rotated through the Dana-Farber Cancer Center. I cared for FW, a patient with metastatic breast cancer. After a day off, I entered her room on pre-rounds to find her gone. I asked my co-intern, who had covered me the previous day, what had happened. He reported:

When I saw FW in the morning, she smelled of stool. I had taken care of her before and knew that that was not like her. I did a rectal exam and found that she had no anal sphincter tone. Long story short, MRI, cord compression, now on neurosurgery.

I remember being a bit freaked out. I thought, "Did I miss something? I hope she’ll be OK. Wow, my co-intern is much smarter and more attentive than me!”

What I took from the experience was that it is important to use all your senses and to act on findings, even if your patients do not report them. This has served me well dozens of times. I’ve picked up on things I would have missed with four or five of my senses. (I plan to retire without using taste).

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An aside – this dedication did lead me astray recently. I was staffing another patient in our urgent care. She was in with a troublesome cough. As I stood in the exam room, listening to the intern’s presentation, I was overwhelmed by a fecal odor. As the intern presented, I grew increasingly irritated that he was ignoring the olfactory elephant in the room. My irritation peaked when the patient’s phone rang; she picked it up and put her sister, who had driven her to the appointment, on speakerphone. I thought to myself, what has happened to social decorum?

The patient’s sister asked her, “Did you step in dog poop? I think you got it in my car.”

Diagnosis made.

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Back to incontinence.

During the second year of residency, we had a geriatric OSCE. There were three or four cases with standardized patients, monitored on CCTV by geriatrics attendings. I remember doing fine on the syncope, falls, and end-of-life planning cases but being completely flummoxed by the 80-year-old woman with incontinence. If I remember correctly, my differential started and ended with UTI.

After the “visit,” I met with an attending, Catherine DuBeau, to debrief. I admitted that we had discovered a gaping hole in my medical knowledge. Dr. DuBeau took me through the classic incontinence 2X2 table.

I have used this table, with the addition of epidemiology and therapy — non-pharmacologic, pharmacologic, and surgical therapy — for the last 30 years in practice and to quiz medical students.

In the same year of residentcy, now working in the emergency room, I met an older man with new-onset incontinence. My differential, though more extensive than it was 9 months earlier, remained inadequate. A senior resident, my colleague and ER backup, gave me a quick tutorial on the causes of acute incontinence using the politically incorrect mnemonic DIAPPPERS. It is one of the few mnemonics I still remember.¹

Diapppers:

D: Delirium or dementia

I: Infection

A: Atrophic urethritis or vaginitis

P: Pharmaceuticals

P: Psychological disorders

P: Poor hygiene

E: Endocrine (diabetes insipidus, mellitus)

R: Restricted mobility

S: Stool impaction

My ability to diagnose and manage incontinence began with three memorable patients (two real, one standardized) and three memorable teachers (two colleagues, one attending). Add to this years of clinical experiences, and I’m pretty good at diagnosing and managing this problem.

I imagine we all carry around a collection of teachers and patients who helped us learn and remind us how to practice medicine.

1. That’s not actually true; I remember mnemonics – Some Lovers Try Positions That They Can’t Handle – but can’t remember what the S, L, T, P, T, T, C, and H stand for.