Diagnostic Limitations
Dr. Milyavsky submitted this piece in response to my most recent Friday Reflection. It looks at similar issues from a different angle -- the ground floor ER rather than the 3rd floor medicine clinic -- and comes to subtly different conclusions.
Adam Cifu
I was working in a community ER in Florida. The patient was a thin, healthy appearing 25-year-old woman with multiple complaints. Sometimes, when she stood up, the skin on her shins would turn blue. She had an uncomfortable tingling sensation throughout her body. It made it hard for her to sleep. At times, she would get shooting pains in her fingertips, seemingly for no reason. Her symptoms were not associated with temperature. She also had frequent headaches. Her symptoms caused her to have significant anxiety.
This had been going on for a very long time, years in fact. She had seen multiple different doctors, including a neurologist and a rheumatologist. No conclusive diagnosis had been made. All her labs and imaging studies had been normal.
Given the fact that there seemed to be both neuropathic pain as well as some mental health symptoms, I thought I had a bright idea. “Why don’t we start you out on venlafaxine?”
“Oh, Effexor? I tried that for like five years, it didn’t work. I have an appointment at the Mayo Clinic in two months.”
You get the picture. Here was a patient with symptoms that caused her significant distress. I knew within 30 seconds of talking to her (or just from reading the triage note) that I would not be able to figure out what was going on with her in the ER. To be honest, I wasn’t even sure if the most extensive work up by the most knowledgeable sub-specialists would lead to a diagnosis. They might slap a label on it: fibromyalgia or chronic fatigue syndrome, or myalgic encephalomyelitis. But in terms of being able to explain what was causing the symptoms, on a pathophysiological level? Unlikely.
Dr. Cifu’s recent post got me thinking – how often am I using the fact that I’m an Emergency Medicine doctor as a cop out? It’s certainly true that the main purpose of the ER is to rule out immediate threats to life and limb, but that can also be used as an excuse to avoid thinking about the problem any further.
What is the line that divides a true diagnostic enigma, that is, a diagnosis that is very difficult to make but achievable, from one of those things that modern medicine simply doesn’t have the answer for? I don’t know, but maybe the failure to diagnose isn’t always a failure, but rather more of an opportunity to express compassion and find other ways to help. It may not feel as satisfying as diagnosing an upper GI bleed and seeing the patient feel better after a blood transfusion, but it’s just as vital a part of our job.
When patients present with vague and chronic symptoms affecting multiple organ systems, it can be frustrating for both the physician and the patient, and I certainly don’t have any magical solutions. But maybe the place to start is to acknowledge our diagnostic limitations, while realizing that our therapeutic interventions aren’t just limited to pills and procedures.
Daniel Milyavsky, M.D. is an emergency medicine physician at Creighton University Medical Center - Bergan Mercy in Omaha, NE.
Photograph by Sami Salim
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Go blue jays!!!! Lucky for BMMC and Omaha to have you. Glad to see another chi md and Omahan reading Sensible Medicine. Great post. Full agreement here.
All of us who have practiced emergency medicine, or medicine in the emergency department in countries where this specialty doesn’t exist, have seen this kind of patient. Good for her that she was not critically ill, but her constellation of symptoms and signs are suitable for a MGH case presentation in the NEJM.
Getting the right diagnosis is a Sherlock Holmes / Dr House challenge. The patient is way beyond of what we frequently see in practice.
What about using AI in order to get the differential diagnosis and reach the right one?
Having the right diagnosis would help her understand what really happens and how to mitigate it if there is no definitive cure.
Of course, all patients are bodies and souls and we as a practitioners have to treat both. There are no illnesses but patients.