Another Case of Medicine Gone Wrong

A Follow-up to Friday Reflection 59

PM is a 55-year-old man who presents to a primary care clinic with two weeks of chest pain. When the pain began, he was seen in an emergency room in another country, one with excellent healthcare. There, he had a normal EKG, negative troponins, negative coronary CTA, and a near-normal coronary artery calcium scan. He was told to follow up with his doctor when he got home for a stress test.

There is no reason to write another piece on a missed diagnosis. I hate it when doctors complain about the care other doctors provide. Usually, the other doctor was doing their best, and the untoward outcome was due to a bad disease rather than a bad decision. If a mistake was made, it was likely made with all the best intentions.

Also, judging others makes me seem like an old curmudgeon or a self-important jerk.

The misdiagnosis I wrote about last week and the one I write about today are related. They reflect a systemic problem in medicine rather than the failure of a few doctors.¹ Last week, I described the problem as treating rather than healing. Another way to describe the same phenomenon is the attractiveness of the rule out.

When I was an intern, I admitted a patient with chest pain for rule-out MI. Back then, it took 24 hours, 3 CK-MBs, and 3 EKGs to accomplish the rule out. The next day, after the MI had been ruled out, we discharged the patient. This might be an exaggeration, but my memory is that as we wheeled the patient out of the hospital, her last words were, “What about my chest pain? You haven’t done anything about my chest pain!”

PM sent me a MyChart note that included his test results, asking me to schedule the stress test. It seemed worth our time to actually see each other.

I have seen PM for over 20 years. He is healthy, takes no medications, exercises regularly, and presents his concerns and symptoms in a straightforward manner.

At our visit, PM told me that his symptoms had started about a week before the emergency room visit. He did not have chest pain or pressure or even discomfort; he was just “more aware of his heart.” This awareness was constant. He did notice it more when he exercised. During exercise, the symptoms could best be described as palpitations. The rest of the history was unremarkable. There was no dyspnea, no leg swelling, and no symptoms of infection or bleeding. As far as he could tell, things seemed to be getting better.

PM’s physical exam was notable for a pulse in the low 90s, about 30 points higher than his usual. There were no signs of anemia, no edema, and his heart and lung exams were normal. His thyroid gland was tender.

Laboratory data revealed a normal CBC, a negative d-dimer, and moderate hyperthyroidism. His symptoms resolved with a daily dose of 60 mg of long-acting propranolol, which we stopped two weeks later. Four weeks after our visit, his labs showed him to be mildly hypothyroid. Four weeks after that, his labs were normal.

Diagnosis: thyroiditis

As in last week’s post, you could argue that PM received perfectly good medical care.² Serious medical problems were ruled out in urgent care clinics and emergency rooms, and the definitive diagnosis was left to a setting where more thoughtful care could be provided. Medicine has improved because the wide availability of advanced diagnostics now allows us to test people for the serious, life-threatening diagnoses (must-not-miss diseases in the verbiage of Symptom to Diagnosis) even when the probability is low. The test threshold for every disease has fallen. I may have benefited (this week more than last) from the differential diagnosis having been narrowed by the doctors before me.³

I appreciate all of the progress in medicine, but it leads us to practice cognitively lazy, expensive medicine. Both this week’s and last week’s patients required multiple visits to get a diagnosis, which could have been made at the initial presentation. They were also overdiagnosed, given diagnoses (cholelithiasis and coronary artery calcifications) that will almost certainly not help (and might harm) them.

The doctors who saw MP mischaracterized his symptom. They interpreted palpitations, likely due to tachycardia, as chest pain. They were encouraged to do this by protocols that indicated a clear work-up for chest pain. They pursued the must-not-miss diagnosis without considering the most likely and most common diagnoses. They used sensitive tests to rule out disease, rather than specific tests to rule in disease. They sent my patient home, telling him that the chest pain he didn’t have was (probably) not due to cardiac ischemia, while he was still having symptoms.

Medicine practiced well means spending money on 21^st-century diagnostics when they are indicated. This includes testing people with lower disease probabilities than in the past. Medicine practiced well, however, also means practicing medicine. It means getting a history, generating diagnostic hypotheses, testing those hypotheses with questions and a physical exam, and then using technologies to evaluate the likely diagnosis.

Harumph. I’ll lay off being an old curmudgeon or a self-important jerk for a while.

1. I write this even though I generally hate not blaming the person who made the mistake (in addition to blaming a broken system).

2. A serious thank you to Barry, whose comment really got me thinking.

3. I solved Wordle in one guess, but I looked at someone’s phone who was on their fourth.

Photo Credit: Joachim Schnurle