Going nowhere fast

One of my attending physicians is fond of saying that most physician errors are not errors in treatment, but errors in diagnosis. The patient is getting the right treatment for the presumed diagnosis, but the diagnosis is incorrect. It doesn’t do much good to treat a febrile patient for pneumonia if they actually have pyelonephritis.

This creates a big challenge in a residency program – a lot of hand-offs take place, and most of the time we get only a brief summary of the patient’s course. My co-resident tells me that a patient has pelvic inflammatory disease, and I pretty much take it on faith that she knows what she is talking about. There is a tendency to continue treating the patient for the diagnosis that comes in sign-out, even if evidence appears that suggests that this diagnosis may be incorrect.

In fact, I recently had a patient appear in my clinic for follow-up of endometriosis. She had seen several of my colleagues, each for only one appointment. Continuity of care is very challenging in a resident clinic, and it’s very common for patients to see multiple providers like this. Each visit said that the patient was presenting for follow-up of endometriosis. She was receiving appropriate treatment for endometriosis (a trial of combination oral contraceptives, followed by depo-provera injections), but she wasn’t getting better. When I walked into her room and asked my standard “What brings you in to see me today?” she responded by saying she wanted a referral to an endometriosis specialist.

When I asked her how she had been doing since her last visit, she told me she was “still” having pain every day. She also complained of diarrhea, muscle cramping, and back pain. For those who aren’t familiar with endometriosis, this is a bit of an odd picture for endometriosis. Patients with endometriosis have tissue that should be growing inside the uterus growing in other places in the pelvis. This tissue tries to have a period every month, so it grows and sheds on the same monthly cycle and the tissue inside the uterus. Patients typically have pain leading up to their period. Constant pain every single day doesn’t quite fit.

So, to make sure I wasn’t falling into a trap, I started asking more questions. When asked how she was first diagnosed with endometriosis, the patient answered “Based on my bad periods and my family history.” She started telling me how her mother had endometriosis, and how she had had heavy periods since menarche. She had never had a laparoscopy, which is the gold standard for diagnosing endometriosis. But someone told her in her teen years that her heavy periods and pelvic pain were endometriosis, and every physician she had seen since appeared to be taking this diagnosis at face value and treating her for it.

On her physical exam, there were no distinctive features of endometriosis. That, in itself, doesn’t necessarily mean she doesn’t have endometriosis, though. More revealing was the fact that she had spasm and tenderness in the muscles of the pelvic floor. In other words, I suspect that her constant, daily pelvic pain is related to muscle spasm rather than to endometriosis. She has been telling every doctor she sees that she has endometriosis, and everyone has been treating her for endometriosis, but it’s possible that she doesn’t have endometriosis after all.

Incidentally, this is also the danger of patient self-diagnosis – the patient comes in with irritable bowel syndrome, fibromyalgia, endometriosis, or anemia on their chart and it’s easy not to dig too much deeper into the workup behind that diagnosis. Then, months later, your patient isn’t feeling any better and you finally realize that she never had that problem to begin with. I can’t tell you how often a patient tells me she had “thyroid problems,” and on further questioning this is a self-diagnosis based on the fact that she has gained weight recently. Interestingly enough, there seems to be quite a constellation of these common self-diagnoses (more in another post). Patients rarely want to lay claim to things like diabetes, hypertension, or PCOS…

I sent her to a physical therapist who specializes in chronic pelvic pain and pelvic muscle spasm, and we will see how she does!

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