Monday, November 12, 2007

Diagnostic skills

A friend who is a primary care doctor once told me that 85% of the symptoms that he sees in patients don't matter. They will simply go away over time. Jerry Groopman notes the same in his book How Doctors Think (on page 100): "Nearly all of the complaints patients describe to their primary care physician, such as headache, indigestion, and muscle pain, are of no serious consequence."

This makes it all the more impressive when a PCP has the diagnostic skill to notice the symptoms that do matter. This is especially the case for pediatricians, who often have to rely on noncommunicative patients and parents' descriptions of their child's symptoms. Two stories of this ilk follow.

A baby and mom go to visit the pediatrician for a "well child visit" several weeks after the child's birth. Everything seems normal, and the visit is about to end. The doctor closes with one last question: "Is there anything you have noticed about Sally that has you curious or concerned?" Mom replies, "Well, I notice that she sweats a lot while nursing." Alarms go off for the doctor, who suspects a problem and orders tests. It is found that the child has a rare heart defect that prevents proper blood flow, particularly during the somewhat strenuous nursing activity. Cardiac surgery is undertaken, and the baby is fine, avoiding major complications that might not have showed up till years later.

Another child, a two year old girl, returns to the PCP with the second urinary tract infection ("UTI") in as many months. Alarms go off for the doctor. After assuring herself that the parents are using proper sanitary practices during diaper changes, she orders a test of urinary function that indicates reflux of urine from the bladder back to the kidneys. The little girl's ureters are not properly implanted in the bladder, permitting backflow. The pediatrician notes, "I've seen too many teenage girls with kidneys damaged from years of undetected reflux and persistent UTIs." After several months of prophylactic antibiotics to see if the girl will outgrow the problem, she undergoes surgery in which the ureters are re-implanted, and the UTIs stop.

6 comments:

Barbara K. said...

These are great stories. How little it takes for the health care practitioner to ask, "Is there anything else you're concerned about?" Yet what an important, and too often overlooked, question.

Marc Theilhaber said...

Nice stories, but not necessarily shining examples of amazing health care.

Story 1 makes you wonder a bit about the quality of the examination part of the well child visit. Why did the pediatrician not pick up this gross cardiac abnormality (which you seem to be describing) at the examination stage of the visit? Or earlier, when the doctor asked about feeding? Yeah, good that it was picked up, but not really something to pat yourself on the shoulder about.

Story 2 isn't that clear cut either - actually far from it. The attributed role of UTIs in the development of renal impairment / chronic renal failure (to which you are referring) seems to be constantly shifting. Also, the value of prophylactic antibiotics to prevent UTIs in children is questionable at least (compare Conway et al, JAMA 2007;298(2):179-186)

Just for fun ask your general pediatricians and pediatric nephrologists about the controversy around the latest NICE guideline (UK National Institute for Health and Clinical Excellence) on urinary tract infections in children

And while am on a rant: Hardly any pediatric patient is noncommunicative. Most of them are far more communicative than your average geriatric patient (just guessing, I only treat pediatric patients). The fact that the younger ones or children with severe developmental delay don't talk does not mean they don't communicate.

Anyway, thanks for your interesting blog! (Could do without the soccer bits, but then again - I don't have to read them if I don't like them).

Cheers,
Marc

Anonymous said...

As a reader of your blog who has been a patient in your hospital, I would like to respectfully note another side of the statement that "85% of the symptoms that he sees in patients don't matter." As a patient, sometimes one sense that the primary care is not taking what you are going through seriously for this reason. As an example, I recently had a bout with very bad headaches. Because I had experienced migraines all my life and was going through a very stressful period, the headaches were initially written off as stree-related or possibly sinus-related. It took a specialist to find a bone spur in my sinus cavity, and even after that diagnosis I had to wait an extended period of time for surgery and recovery. During all of that time I was in a great deal of pain, but because I presented as a stressed individual, I often felt that my pain was somewhat written off as something that "didn't matter" because it wasn't life-threatening. I spent many weeks in unnecessary pain due to delays in getting specialist appointments and attention to my problem. I don't fault any particular person, necessarily, but sometimes pain "matters" a great deal to the patient even if the doctor does not consider it seriously. It was a huge relief, after switching primary care doctors, to find one who said to me, "pain is serious because it is affecting your life, period."

Paul Levy said...

Marc,

Thanks. We don't do pediatrics at our hospital -- except for newborns -- so I don't have anyone here to ask -- but thanks for the thoughts.

Sorry, soccer posts are likely to continue from time to time!

Anon,

I'd like to recommend Jerry Groopman's book, in that he discusses exactly those kinds of issues.

Betsy B. said...

I know a woman who had this very problem as a child. Her constant wetting was blamed on her parents divorce, and she was sent to a psychiatrist (no offense, in this case it just wasn't the correct thing to do.) She was forced to wash her own sheets and other things to "correct her behavior!" Thank goodness a new primary care doctor decided to order more tests and discovered the reflux. She is still scarred by the experience.

Anonymous said...

Sometimes the hardest thing is finding a doctor who will plainly *say* that it doesn't matter. You go to the doctor wanting to make sure that the stomachaches you've been having aren't an ulcer or the little rash your kid has that isn't really bothering them isn't a food allergy. They order some blood work, don't really see anything and refer you to a specialist. The specialist doesn't see anything but asks you to come back in few months or a year, and meanwhile there's a note with the name of whatever disease that you haven't exactly been diagnosed with in your medical record, so now you pay more for insurance or, if it's your kid, the school gets nervous and wants to treat her differently. This has happened to me more than once and it's just Kafka-esque, all the anxiety you go though because the doctor won't exactly say you're healthy. And maybe it's just because they can't really ever say you're healthy, because then they'll be liable for malpractice if someone ever finds anything wrong, but when do you stop worrying about if the professional doctor won't give you a clean bill of health?