Dr. Sam Parris was an internal medicine resident running behind schedule. Her next patient, Mr. Henderson, was a 64-year-old man with a reputation for being talkative and sometimes forgetting details about his medical history or giving contradictory answers.

Most recently, Mr. Henderson had come in for fatigue and had been reporting that he wasn’t enjoying activities that he used to love, like tending his garden. “I think I’m just getting old,” he frequently said. He had seen a cardiologist and a neurologist, both of whom found nothing wrong. Sam scanned the previous notes: "Patient denies chest pain. EKG normal. MRI normal. Likely dehydration." Each time he had been assured that nothing seemed wrong, and was sent home only to be back in a few weeks reporting the same issues. Although he did have some chronic conditions that brought him into the practice fairly regularly, Sam suspected that Mr. Henderson was also lonely, and appreciated the chance to get out of his house and to have someone to talk to.

Typically, Sam would try to indulge Mr. Henderson as much as she could, but she had to admit that this last round of visits had been frustrating. He typically followed her advice and accepted her explanations. “Whatever you say doc! You’re the expert,” was a frequent refrain. His next visit outside of his routine care, which was never long in coming, would generally be for some new and mild issue. But this time, he continued to insist that something was wrong despite no medical evidence to that effect, which Sam attributed to the fact that as she and her staff grew more accustomed to his frequent visits, he was being given less of their time and attention.

On this day, Sam was already behind and had a few serious cases waiting. Her patience was thinner than typical, and she entered the room, prepared to get Mr. Henderson in and out quickly. "Hello again Mr. Henderson," Sam started. "So I hear you're still feeling fatigued. How have you been sleeping?” she said, trying to get through a few rote questions as quickly as she could.

“First of all,” Mr. Henderson began, “When I was in here last time because I couldn’t go to the bathroom—well you’ve cured me of that! No problems there anymore, doc!”

“That’s great to hear, Mr. Henderson. Now, as we’ve told you before, everything else looks good. Your blood pressure is under control. I’m going to recommend that you try to regularly drink more water.”

“But doc, listen to this…” Mr. Henderson then began a long, winding story about his garden, his late wife, and the heat wave last summer. As he went on, Sam’s mind wandered and she was about  to interrupt and steer him back to the relevant medical facts. However, something, maybe subconsciously, stopped her and she wondered if she’d been slipping in her commitment to doing her due diligence. She decided to lean in and set efficiency aside for a moment.

She put her pen down. "You mentioned your garden," Sam said. "Tell me more about what you do out there."

Mr. Henderson lit up. As he started talking, Sam took a closer look at him and noticed that he seemed paler than usual, and that he also seemed to be increasingly short of breath the longer he talked.

Suddenly, something clicked. “Mr. Henderson, I’m sorry to interrupt, but one question. You mentioned you’re no longer constipated. How many times a day are you going now?” It then very quickly became clear that not only was he no longer constipated, but that he was having multiple loose black stools each day. He wasn’t dehydrated, he was experiencing a potentially serious GI-bleed that had gone undiagnosed because of how he had been describing his symptoms. It was quite lucky that Sam had not just sent him on his way with instructions to drink more water. The real problem had been a mismatch between Mr. Henderson’s language and the medical diagnosis.