Fast forward 4 months: We had married and just moved out of state. On our first weekend in our new home, he experienced serious abdominal pain in the LUQ–or ULQ–whichever. We were new in town, but knew a few people, one of whom worked in a clinic and recommended her doctor. He arranged for us to meet a surgeon at the ER. WBC was normal, but the doc said he wouldn’t be surprised if it were appendicitis, especially after hearing about the earlier episode. We went home. Another episode occurred a few months later, with pain in the LLQ, after which our internist said my husband was going to give him and the surgeon coronaries. Appendicitis was still the primary suspect.

About a year after the first episode, my husband went to bed complaining of severe pain in the RLQ. He woke me up at 4 a.m. and told me to call the doc. This time the WBC was abnormal.

Surgery was supposed to take about an hour, so I ran home for a couple of his things and got back in about that time. Doc was still in surgery. When he came out, he told me it had taken him an hour to chisel through the hardened poison that had collected around the appendix. He said the thing had been seeping for about a year, and the reason the WBCs had been normal was that Art had previously waited a coupld of days to call the doc.

This is my entry in the “atypical appendicitis” contest.

I went to our physician because I was having a persistent problem with cold feet. They felt cold, and they in fact were cold. I often turn on the heating pad when I go to bed in order to warm my feet. I figured he would say something about circulation, or vitamins. No, his first thought was, “Well, it could be syphilis.” I pointed out that I had been married a good many years and my wife and I were devoted to each other, but he insisted on a blood test. It was negative, as I knew it would be. My wife thought this was hilarious. The physician lost interest in my cold feet.

A year later I stuck the back of my hand with a large cholla pad, and reacted badly, with swollen joints. The good doctor looked at my hand and said, “Well, it could be gonorhea.”

Now I realize that having a physician who thinks of all the possibilities is a good thing, but there is also Occam’s razor, dealing with the simplest solution. I mean, if the patient just had an encounter with a cactus, one really should consider the cactus stickers as the most likely suspects.

Final straw: I was having symptoms of an elephant sitting on my chest, for months. When we went to Ouray, Colorado on vacation, elevations up to 11,000 feet, the elephant vanished. The instant I returned to the desert, the elephant was back. The doctor sent me next door to the emergency room and they performed all sorts of tests, including a stress test on a treadmill. Nothing.

Before you read further, your diagnosis would be…

A year later we had a new HMO and were able to go back to a wonderful physician, the finest we’ve ever met. He is an absolute whiz at diagnosis. I described my symptoms and he immediately said, “You have GERD.”

And he was right. Prilosec removed the elephant.

While that may end up being ‘defensive’ medicine, it is first and foremost GOOD medicine — to not leap to an easy conclusion or be seduced by first impressions. If you don’t utilize the diagnostic tests available in such situations, you may then wish you had — and then it becomes in hindsight ‘defensive’ medicine.

You jump immediately to the extreme position of “No matter what we do it will not be enough! Who will pay for it when we do all the testing for all diseases! We’ll be doing MRIs for hangnails! Therefore we should revert to making clinical diagnoses alone, and prevent people from suing us.”

There is a middle ground, but you’re not seeing it. No, the middle ground has no hard and fast boundary, because there’s no such thing. The linked article has a really good point that you are missing, and I don’t know why you won’t see it. It says don’t be so cocky that you miss a blown appendix because you think CTs are stupid and the patient must have the flu. There is a lot of space between “Who’s going to pay for all this! I won’t do it!” and considering the risks when sending home a hot appendix to return to you ruptured or dead.

It’s not intended to be an offense to your abilities — the linked article is encouraging you and all docs to keep an open mind and employ diagnostics where the risks of error to the patient (not the doctor) are catastrophic and the prevention would be significantly less so.

This still involves judgment calls; if you don’t want to be making them, then maybe medicine isn’t a good place for you. The point of the linked article (let me say it again) is to be more balanced in how you approach diagnosis. It’s a good article, calm and wise. Please read it again.

“Genius MD” says, “The best therapy more often than not is observation of the patient, and the tincture of time.” Nice onomatopaeia, but when the risk of a ruptured appendix is stacked against a CT, why not do the CT? First you have to decide that it possibly IS appendicitis, and the linked article is encouraging you to keep an open mind and not dismiss the possibility out of hand. It’s a matter of a more mature approach to practice.

Genius the MD also says, “Cope wrote of how poor surgeons rush patients for exploratory laparotomy who did not have any physical problem, simply because they had no clinical skill to tell the difference.” What a load of value judgments in THAT sentence. In this ‘earlier, more sensible time’ that Genius harkens back to, there weren’t CTs, and all that was possible WAS deployment of clinical skills. And mistakes got made, and people got operated on who shouldn’t have, and others who should have didn’t (and often died as a result). But now that you have CTs etc., why not use the technology to narrow the margin of error instead of Genius turning it into an ego thing to brag that he has such superior clinical skills that he doesn’t need those silly CTs. That is the very definition of arrogance and won’t look good on the witness stand. Pity that the patient may well be dead at that point.

Keeping the PATIENT out of trouble will keep the DOCTOR out of trouble, DR GENIUS.

“Unnecessary” testing is certainly a debatable point – where do you draw the line?

Would you obtain an MRI for every back pain? A head CT for every headache? A stress test for every chest pain?

Because, there is always a chance that the back pain can be a meningeal abscess, the headache a brain tumor, and the chest pain angina. Anything is possible in medicine.

However, who pays for all this testing? MRIs and CT scans aren’t cheap. If every symptom was worked up to the max, health care costs will balloon through the roof.

With defensive medicine and doctors’ CYA mentality, this is happening already.

Remember, more tests does not equal better care.

Thanks,
Kevin