The apprehension of 'not knowing'

Mr. U is a Malayali gentleman settled in Tamil Nadu for more than 40 years now. He speaks Tamil with such a beautiful Malayali accent, that it sounds like poetry. He retired from a very important position in a central government organisation. You can feel the sense of pride and responsibility of having been in an important post in the way Mr. U dresses, walks, talks and carries himself. 

"You won't mistake me if I ask you a few questions, would you?" He would preface his interaction after the clinical encounter with this question. After I say that it is not at all a problem, Mr. U would take out a small pocket-notebook and flip a few pages and start the questions, which he would have jotted down in it- 

"Doctor, I like to eat fish curry at least 2-3 times a week. Is that alright? Will it affect my blood sugar control?"

"When my grandchildren are visiting our home, my wife makes some sweets for them. I am unable to resist the temptation to taste them. Can you advise me how many pieces I can have?"

"I saw this advertisement for a new detergent powder. Can I wash my undergarments in that new detergent? Will it affect my fungal infection that I have?" 

These are just a few questions that Mr. U has asked me over the past few visits. I am amazed at his attention to detail and the specificity of his questions. Some of his questions make me wonder if we all must pay such close attention to our health. Many things which we take for granted, Mr U pays a lot of attention to and ensures that he does them in a manner that promotes his health. Some of his questions are complex. I have had to read up extensively to answer them. 

One particular Sunday, Mr. U came to show me a small infection on his foot. There was a crack in the foot, which had gotten infected and it was swollen and hurting. I dressed the wound and started him on antibiotic medications to cure the infection. He came back in a couple of days for dressing of his feet. "Doctor, my wife makes the best fish curry, but of late I am not able to taste it. I get only a bitter taste in my mouth. My taste is messed up. Can you please explain why my taste is altered?" When he first asked me this question, I did not know the answer immediately. I told him that I will find out and explain it to him. I took his phone number and gave him mine. That day after the clinic, I went home and read up about altered taste in a person with diabetes and high blood pressure on treatment. My usual Go-To places to read are UpToDate for which I have a complementary subscription thanks to The Better Evidence UpToDate Donation subscription offered by Ariadne Labs for physicians from low resource settings. UpToDate threw open an ocean of differential diagnoses for altered taste, which is known as dysgeusia in medical terms. Detailed reading led me to understand that some medications can commonly lead to metallic or bitter taste in the mouth. Metformin, the diabetic medicine, Enalapril, the high blood pressure medicine, and certain antibiotics like tetracycline, metronidazole etc. can cause bitter taste in the mouth. He has been on Metformin and Enalapril for a long time, and it has never led to bitter taste so long. So it is unlikely that it suddenly caused it. He was not on any of the other drugs that commonly cause bitter taste. I was puzzled. Mr.  U called me again the next day on phone and asked me to explain his altered taste. I still had no answer. I said I am still looking. By now it had led to significant distress to him. All my readings had been consumed by my attempt at finding an answer for why Mr. U's taste was altered. Mr. U seemed to be in otherwise good shape, even his foot ulcer was healing well. The only new drug that he was using was cephalexin, the antibiotic for the foot infection. So it has to be cephalexin induced taste alteration. But there was no report of cephalexin having such a side effect. I was questioning myself if I was suffering from an anchoring bias. Am I anchoring my diagnosis to cephalexin induced altered taste and hence not thinking of other possibilities? The week passed without me arriving at a definite answer. 

Mr. U came back next week for having his foot ulcer dressed and for a follow up. The ulcer had healed well. I felt a bit helpless as I did not have an answer for his question. Mr. U never brought up the altered taste. But I couldn't leave it at that. So in a very hesitant and apologetic tone, I asked him, "What happened to your taste sensation now? Is it any better?" Mr. U gave me a simple smile and said, "I thought you had forgotten about it. It is much better now. I could start tasting food properly 2 days ago and it is improving now." The only thing that had changed was that Mr. U had completed his course of cephalexin three days ago. I still don't know if the altered taste was due to cephalexin, or whether it was some inflammation in the body due to the infected wound in the foot, or maybe he even had a mild fever due to the infection which was unrecognised. Mr. U must have sensed my feeling of defeat or shame in not having an answer for his question. Being a sensible and senior man, he must have sensed my deep seated insecurity and need to always know answers. He spoke to me reassuringly and said, "Doctor, whatever the reason may be, now my taste is better. I am not bothered about it anymore. You shouldn't be either."  

Sometimes, patients like Mr. U ask us very simple questions which don't have such simple answers. I have encountered numerous situations where I don't have answers to questions that patients ask. Though the feeling of insecurity and incompetence of not knowing has slowly reduced over the years, I still struggle to acknowledge that sometimes we just don't know. While 'not knowing' about the cause of altered taste blew past Mr. U once his taste became better, it was not easy for me. For me, it was not just altered taste, it was a challenge to my competence as a physician and a person who knows and understands the human body. The uncertainty and helplessness that accompanies 'not knowing' is a universal emotion. Mr. U could sense that in me and responded to me intelligently and sensitively. How I handle 'not knowing' nowadays is by trying my best to know about it by reading, but ultimately acknowledging that it may not be possible.