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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Very often people are seeking care, the feeling of being seen and looked after. When you feel crummy you want someone to take the lead and make it better in some way. As healthcare providers that is fundamentally our job. Obviously accurate diagnosis and treatment are part of it but if you don’t feel cared for- that wont do the trick. I have been a nurse for 29 years and my most important tools in making people feel better are juice boxes, cups of tea and an offer to hear their story. Ten minutes and a few tears or laughs later, and they feel better (was that not the goal?) and ready to hear what I or the doctor are saying. Often what they needed most was someone to bear witness to their suffering. Because they feel heard they reveal much more, often giving you the tidbit of information that makes the diagnosis much easier.
This process of taking the lead and looking after someone also impacts those of us doing it. You Understand that you are their best bet in this moment. Feeling your caring with the power you hold in that moment- renders you the most creative you can be- you are the answer for this person right now- what can you employ to identify their issue and make it better?
As humans, we are literally designed to exist in families and communities of cascading care. When someone presents their vulnerability to you, your most beautiful human instincts should lead you to take the lead and look after them- how to look after them will become obvious when you start from there.
Thanks for the thoughtful article.
Now retired, but I once was an emergency doctor, and have done 40 years of family practice.
I wonder, when I read a clinical scenario like the one you describe, what the patient herself was hoping to accomplish in coming to the emergency department. What was the emergency? She’d had the problem for years, had tried various therapies, no doubt had undergone endless testing, and was awaiting a (more likely another) specialist assessment. What hope was there that you would figure it all out, when nobody else had?
Put another way, you were thinking she wanted a diagnosis. She probably had another goal in mind, maybe compassion, maybe a brief respite from her symptoms, who knows. Sometimes I would simply ask the patient what they hoped to achieve when they came today. The answers often surprised me, in that what they wanted was quite realistic, often fairly basic, and easily provided.