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Symptoms Don’t Read Medical Textbooks

May 27th, 2009 by DrRob in Better Health Network
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“That doesn’t make any sense.”

The patient sits across the exam room and looks at me with a combination of surprise and hurt.  He had answered all of my questions to the best of his abilities, hoping that I would figure out what was causing the symptoms and fix his problem.  A bit of doubt shows on his brow as he goes over what he feels and what happened in the past.  Did he say things wrong?  Did he mistake the way it felt?  Is he just bad at explaining things?

“I am not accusing you of being untruthful.  Your symptoms are your symptoms, and you felt what you felt.  Unfortunately they don’t always read the medical textbooks and so make me earn my keep.  I believe your symptoms are real; I just don’t understand how they fit together.  It’s confusing.” I say this as reassuringly as possible.  He relaxes visibly as I speak.

But that doesn’t change the fact that the symptoms defy logic.  It’s my job to figure things out and fix things, right?  Isn’t this an admission of defeat?  Isn’t it a confession of my inadequacy?  Won’t this undermine the thing that I have said is the cornerstone of a doctor/patient relationship: trust?

Some people seem impatient for an answer, but most are OK with me not knowing for a while.  The thing that makes it acceptable for me to be confused is the longstanding nature of the relationship of a patient with their PCP.  This is one page in the book, not the whole story.  This concept – of the patient’s “story” – is one I actually use in this situation.  I say:

You know when you see a movie that is really confusing in the start?  You don’t know who is who, or why one person was mad at the other, etc.  It is just hard to figure out what is going on.  But later on in the movie things become clear.  You say “Oh, so that’s who that guy was!  That’s why she was so mad at him.”  It all clears up over time.  With your illness, we may just be at that confusion part of the movie.  It may just take time for us to be able to make sense of what is going on.

I have to say that I actually am glad for those cases where things are confusing at the start.  No, I am not happy for the patients, but the hard stuff is what separates the good docs from the bad ones.  If I can sort through things and come up with an answer when one wasn’t apparent, I am showing the merit of all of my hard work.  I justify my salary.  I go home feeling like I am more than just a bunch of algorythms.

I don’t want everyone to be confusing, but just because things seem to not add up it doesn’t mean we won’t come to a good answer eventually.

*This blog post was originally published at Musings of a Distractible Mind*

Misdiagnosis Could Have Paralyzed Young Screenwriter

May 3rd, 2009 by EvanFalchukJD in Better Health Network, True Stories
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My younger brother is an executive producer of the show “Nip/Tuck” and an executive producer of soon-to-air Fox show “Glee.“  Last year, he almost died.

It started when he woke up one day with numbness on one side of his body.

His doctor ordered an MRI. It found bad news: a tumor in his spinal cord, high up in his neck. He was referred to a neurosurgeon.

The plan was straightforward, but dangerous.  First, radiation.  Then, his spinal cord would be carefully cut open to remove the tumor. He was told he could end up paralyzed, or dead.  Concerned, he called me, and we started a case at Best Doctors.

One of our nurses took a history, and we collected his records.  Two internists spent hours reviewing them.  The records noted our family history of a kind of malformed blood vessel.  Our grandfather had hundreds of them in his brain when he died at 101, and our father has dozens of them in his.  I have one in my brain, too. This was in my brother’s charts, but none of his doctors had mentioned it.

An expert in these malformations told us a special imaging study should be done to rule this out as a cause of the problem.  Best Doctors gave that advice to my brother and his doctors.  They agreed.

The test showed this was precisely what he had.

Quickly, the plan changed. He still needed surgery — if the malformation bled, it could also paralyze or kill him.  But there would be no radiation, which might have caused the very bleeding we feared.  Even if that didn’t happen, the surgeons were prepared to operate on a tumor.  They would have been surprised to find a delicate malformation there instead.

In the end, his surgery went well.  He is having a good recovery and is busy with his new show.  But his case is a constant reminder of how important it is to have the right diagnosis, and how easy it is for things to go wrong.

Even in  Hollywood.