Seeing is Believing, How Much Will You Believe If You’re Not Looking Thoroughly?   1 comment

I felt like _How Doctors Think_ by Kathryn Montgomery was strongly influenced by her daughter’s early detected breast cancer. 

     On page 84, chapter six, Montgomery states, “At 28, [my daughter] was…far too young, an unlikely patient who might have eluded the attention of anyone reasoning ‘scientifically’ from general principles to her improbable case.  Luckily, medicine is a practice that ignores the requirements of science in favor of patient care.”

     I disagree.  I don’t think her daughter is in the “norm,” but rather lucky to have a doctor who further investigated without delay.  Hypothetically speaking, let’s say her daughter is the “norm” for today’s medical practice.  I think it’s relevant to point out not only was the cancerous breast lump not a transient symptom, but it was something tangible that the physician could physically detect for him/herself, even prior to mammogram.  I feel this is an important aspect of getting a physician to take a symptom seriously enough for further testing.  Seeing is believing, or in this case, feeling is believing.

     In chapter six, page 92, Montgomery asserts, “Physicians have no interest in the individual details or sequences that are not established markers of disease.”  Later on she states, “Once the clinically relevant details of the case fall into a diagnostic category with no leftovers that demand explanation, there is no further need for investigation.”

     This type of thinking can be potentially dangerous for two reasons.  First, how can a symptom detail ever become an established marker of a disease if time and time again physicians everywhere fail to document a detail based on whether it has already been established as a marker of the disease?  Secondly, even Groopman’s_How Doctors Think_ outlines the problems associated with “search satisfaction” that can potentially limit a physician’s ability to make a thorough diagnosis, which can be detrimental to the patient. 

     On pgs 118 – 119, Montgomery recounts a story of a 40 year old man who fit the family history and symptomology of a stroke diagnosis, but thankfully due to a medical student’s attention to detail, the diagnosis of endocarditis was made.  How long after the fever started would the correct diagnosis been made if the doctor had not deemed the potential heart murmur “clinically relevant”?

     Also, I would assert that all details are “clinically relevant” until the patient is sufficiently treated and becoming healthy again.  The diagnosis may be inaccurate or perhaps there is indeed a comorbid diagnosis yet to be made [as in the case of Anne Dodge].  Furthermore, just because a diagnosis is following the “established markers of disease,” should that be used as an excuse to cease investigation into causes and/ or new or supplementary treatments?  Shouldn’t the ultimate goal be a healthy patient regardless of pattern of disease? 

     In the case of a diagnosis that has no known definitive cause yet (such as in the case of Chronic Fatigue Syndrome/ ‘CFS’ or Fibromyalgia/ ‘FM’ or Postural Orthostaic Tachycardia Syndrome/ ‘POTS’) and thus the diagnosis is essentially a ‘diagnosis of symptoms’; why isn’t it standard practice to seek out the cause of each patient’s CFS/FM/POTS instead of stating that what the patient is feeling is just part of the package of their diagnosis dilemma?  If the patient is openly willing to further investigate, why would a physician rather wait for some other clinician or researcher to put out a paper detailing a new-found cause and/ or treatment for the disease, rather than ordering some more non-invasive tests to investigate potential new leads? Is this a result of “decision tree” learned medicine limitations? [see Groopman, pg 5, intro] 

     For that matter, if a situation presents itself in which not only a cause cannot be found but also a diagnosis is eluding, what prompts a doctor to halt investigation and conclude a diagnosis of psychosomatic illness instead of finding a potential “zebra” diagnosis? [Montgomery, pgs 122-125] And when is it the appropriate time to let medical technologies rule out physical illness even when the patient is feeling quite ill; when the illness seems all but invisible to everyone but the patient?

     On the site patients detail going for months and even several years being told that their test results revealed they are “fine.”  It used to be, when a patient had symptoms of hypothyroidism they were simply given a trial dose of thyroid hormone replacement to see if that corrected the symptoms.  Nowadays, hypothyroidism is solely determined on test results, for which there are several that can be ordered.  However, most doctors only utilize a couple of those tests which often miss proper diagnosis.  What makes a doctor stop at just a selective set of tests instead of further investigating in the midst of a patient’s complaints and ailments?  Even when further testing is non-invasive?


Posted August 30, 2010 by jblakescott in Uncategorized

One response to “Seeing is Believing, How Much Will You Believe If You’re Not Looking Thoroughly?

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  1. Your “feeling as believing” statement made me think of my father-in-law, who went to his doctor about a lump in his neck. After the doctor felt the lump, he concluded it was just a cyst that needed to be surgically removed. If his physical exam had gone further, he might have discovered smaller lumps along both sides of the neck and recogized the possibility of lymphoma–the correct diagnosis.

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