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Unlearning the Diagnosis
Patients and healthcare providers LOVE a “diagnosis,” am I right?!?!
Pain diagrams are used in clinics to allow people to illustrate where they experience their pain. It’s an interesting exercise because you see a wide variation of pain patterns. I like when patients fill them out so that I have a rough idea of what parts of their bodies are giving them problems. One day, a patient came in and did not fill out the diagram but wrote down the words: adductors, piriformis, gemelli.
This triggered many questions:
- Was she right?
- That’s super specific. How did she come to this conclusion?
- What do I say if she’s wrong?
- Does anybody have to be “right” as long as they get better?
After residency, I decided to make it a general rule not look at patient’s chart before I walk into the room. Why you ask? As a resident you learn from a multitude of people with years of experience. Early in your career, you believe everything that you hear and see. With more experience I started to wonder if my teachers were right. Was the orthopedic surgeon who saw them first right? Once a diagnosis has been made it tends to follow patients around whether it’s true, false, or somewhere in the middle. However, we all have a tendency to see some things and miss others aka biases.
Are you sure that the person that made the diagnosis was looking at all possibilities or just the ones they believe to be true?
So when this patient comes in with a diagnosis I had to question how did she arrive at this conclusion! Did she look up the anatomy and figured that these muscles are in the general location of her pain? Did she see a physical therapist that told her that these were the problematic muscles? Did she Dr. Google herself?
“The eye sees only what the mind is prepared to comprehend.”
I treat each patient like there’s a case to be solved. Like any good detective, I interview, examine, and come up with list of possible causes. One of my favorite shows growing up was House, M.D. He always thought outside of the box. Despite his bedside manner, he always came with an objective mind developing a long list of potential diagnoses every episode.
For that reason I don’t like to look at the chart because it limits my ability to come up with a list of potential problems. Several years ago I saw a patient that complained of back and hip pain for 2 weeks. I inadvertently saw the MRI and saw he had a pretty large size disc herniation in his back. Damn! My objectivity has been tainted! After my examination I found that the symptoms were actually coming from the hip joint. But in my mind’s eye, the disc herniation was hard to ignore. I thought to myself, “that herniation is too big not hurt.” Right? Not exactly. It is well known that disc bulges and herniations are very common in people without any pain (Jensen et al. 1994). Therefore, not all disc herniations or bulges lead to symptoms. So it’s challenging at times to know if the disc is exactly the cause of the symptoms. If I never saw the MRI I would have strongly concluded that the problem was the hip. The problem I have now is trying to ignore information that’s quite impressive.
So getting back to my patient it turns out her conclusion was drawn from a combination of her own research and the physical therapist who she LOVED! As I listened to their rationale it was a very clear and logical approach to come to their conclusion. However, I had 2 or 3 other diagnoses it could be with a high suspicion that it was a labral injury of the hip joint. I essentially call her presentation of symptoms as…wait for it…BUTT PAIN. “Butt pain” is localized essentially primarily to the you guessed it…the butt. The cause of this syndrome also is very long and distinguished. It could be referred from the spine, the pelvis, the joints of the hip, muscles, nerves, etc. Labral tears of the hip typically present with groin pain but I’ve seen it present in various ways particularly butt pain. So it can be a challenging diagnosis to make because there are many conditions that present the same way. I’ve been fooled many times by this diagnosis but I eventually added it to my list of possible conditions.
As I started to discuss my list of possibilities, she started ruling things out based off of her experience, Googling, and discussions with her PT.
“It can’t be that because it doesn’t radiate down my leg.”
“I don’t remember doing anything to my hip.”
“My PT says that there must be some sort of swelling around the piriformis.”
As we discussed what it could be I could see that this was going to be a difficult case. The simple part for me was developing a list of “could be” diagnoses. The hard part was convincing her to add my ideas to her list. The rationale she presented was quite logical and I agreed with a lot of what she said. However, she was quite resistant to any of my ideas. There are a number of reasons to resist. I suspect that the amount of time and money that she has already invested into her diagnosis is a factor (please see sunk cost fallacy.) I’m always very careful to tug on this thread. I do not want to come across as “well, you’re wrong” to anybody. Proving who’s right or wrong is not my goal but that is how it can come across. Respecting the relationship between the patient and her PT is extremely important. I try to focus the discussion on being constructive and not divisive. I’m the new guy in this picture but does that mean I have bad ideas? If either party is too rigid it can delay a diagnosis and possibly lead to unnecessary testing and treatment. I have seen this a number of times over the years.
So what happened to my patient? We discussed all possibilities and agreed on a workup plan. However, she never came back. I can only speculate why she did not come back. She moved out of town, things spontaneously resolved, or something I said. Maybe she went back to her trusted PT to get his/her thoughts on our discussion. Perhaps she found another doctor that shared her lens of what she viewed as the possible problems. Who knows but I hope she’s better either way.
As humans, we all come in with biases which are molded through our experiences both positive and negative. One of the challenges as a physician is we HAVE to come up with a “diagnosis” or a label even if we are not exactly sure. We have to keep in mind that diagnoses have to be fluid and can change from provider to provider. Therefore, we must be mindful of our limitations and blind spots. The reality is that 75% of problems fall in the top 3. In a busy clinic, it’s easy to narrow your focus down to the most common problems. However, patient’s and health care providers need to keep an open mind to catch that other 25%. People in pain identify with labels especially if it explains why they feel the way they do. So challenging their diagnosis can draw up emotions and sometimes their blinders. Be that as it may, deconstructing someone’s belief system/framework is sometimes necessary in the rehabilitation process. It needs to be approached delicately which is hard to do in the 15–30″ appointment world of insurance based care. That’s for a separate blog though! In conclusion, coming to the table with an open mind benefits both patients and the treating providers.
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