What doctors do when they don’t know the answer

Part two of a series. See also part one.

Previously I’d discussed how most of the time diagnoses are relatively straightforward. But what do doctors do when a diagnosis isn’t immediately clear to them?

Likely one or more of the following:

1. Revert to “novice” thinking. Which, in fact, is completely appropriate. We’re taught in medical school that approximately 90% of all diagnoses are made from the history, so if we can’t figure out what’s wrong, we’re supposed to go back to the patient’s story and dig some more. This also involves reading, thinking, and possibly doing more tests, for which your doctor may or may not have the stamina.

2. Ask a specialist for help. Which requires your doctor to recognize he or she is out of his or her depth and needs help.

3. Cram your symptoms into a diagnosis he or she does recognize, even if the fit is imperfect. Though this may seem at first glance like a thought error, it often yields the correct answer. We have a saying in medicine: uncommon presentations of common diseases are more common than common presentations of uncommon diseases.

In other words, presenting with a set of symptoms that are unusual or atypical for a particular disease doesn’t rule out your having that disease, especially if that disease is common. Or as one of my medical school teachers put it: “A patient’s body frequently fails to read the textbook.”

4. Dismiss the cause of your symptoms as coming from stress, anxiety, or some other emotional disturbance. Sometimes your doctor is unable to identify a physical cause for your symptoms and turns reflexively to stress or anxiety as the explanation, given that the power of the mind to manufacture physical symptoms from psychological disturbances is not only well-documented in the medical literature but a common experience most of us have had (think of “butterflies” in your stomach when you’re nervous). And sometimes your doctor will be right.

A physician named John Sarno knows this well and has a cohort of patients who seem to have benefited greatly from his theory that some forms of back pain are created by unconscious anger. However, the diagnosis of stress and anxiety should never be made by exclusion (meaning every other reasonable possibility has been appropriately ruled out and stress and anxiety is all that’s left); rather, there should be positive evidence pointing to stress and anxiety as the cause (eg, you should actually be feeling stressed and anxious about something).

Unfortunately, doctors frequently reach for a psychosomatic explanation for a patient’s symptoms when testing fails to reveal a physical explanation, thinking if they can’t find a physical cause then no physical cause exists. But this reasoning is as sloppy as it is common. Just because science has produced more knowledge than any one person could ever master, we shouldn’t allow ourselves to imagine we’ve exhausted the limits of all there is to know (a notion as preposterous as it is unconsciously attractive).

Just because your doctor doesn’t know the physical reason your wrist started hurting today doesn’t mean the pain is psychosomatic. A whole host of physical ailments bother people every day for which modern medicine has no explanation: overuse injuries (you’ve been walking all your life and for some reason now your heel starts to hurt); extra heart beats; twitching eyelid muscles; headaches.

5. Ignore or dismiss your symptoms. This is different from the application of a “tincture of time” that doctors often employ to see if symptoms will improve on their own (as they often do). Rather, this a reaction to being confronted with a problem your doctor doesn’t understand or know how to handle. That a doctor may ignore or dismiss your symptoms unconsciously (as I did with my first-ever patient) is no excuse for doing so.

Just which of the above approaches a doctor will take when confronted with symptoms he or she can’t figure out is determined both by his or her biases and life-condition—and all doctors struggle with both. To obtain the best performance from your doctor, your objective is to get him or her into a high a life-condition and as free from the influences of his or her biases (good and bad) as possible.

Alex Lickerman is an internal medicine physician at the University of Chicago who blogs at Happiness in this World.  He is the author of The Undefeated Mind: On the Science of Constructing an Indestructible Self.

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  • Trin

    I had a doctor admit to me that they were looking through a book to figure out my symptoms

    I didn’t mind really as she eventually diagnosed me correctly

    I did find it interesting though

  • Matt S.

    More doctors need to start using the internet as a tool when things just don’t quite seem to fit one of their usual diagnoses. You have to be humble, you have to be able to parse through piles of garbage data, and you sometimes need to be clever about how you search, but it can often pay off with a real gem of a discovery.

    A rule of thumb I live by:

    For the zebras, the wonderful, and the rare subsets, the best thing to do is to turn to the net.

  • Abandoned

    1. Doctors don’t get paid enough to dig deep.
    2. What happens when you stump the specialists?
    3. It’s amazing how many times my illness has been wrongly stuffed in the same box when it clearly doesn’t belong there.
    4. I was lucky enough to have physical evidence of my illness. What doctors failed to realize was the stress/psychological toll that I experienced.
    5. I stopped complaining about my issues, did some CAM to deal with the symptoms. When doctors ask about my symptoms, I tell them I am fine. Primary Care is the worst-I had my PCP argue with me about a reduction in medication ok by another doctor. It’s better just to keep your mouth shut.

  • westeasterly

    What do medical students do when the don’t know the answer? Wikipedia!

  • tgottsdo

    I once had a patient who came to see me with a litany of symptoms… it was my last patient on a friday and I was anxious to go home. She came with her husband and told a story of repeated visits to doctors with the symptoms that were getting worse and worse. Her main complaint was difficulty swallowing and choking on food as well as weak facial muscles. She had already seen a neurologist and a GI specialist… which is usually a bad sign… and usually leaves me with few options. As I listened to her story it became more and more evident what her diagnosis was going to be… like a predator closing in on his prey my questioning became more and more focused. I was shocked that a neurologist failed to make this diagnosis 2 day prior. Finally, I was about to make my diagnosis known when the patient pulled out a home medical book and pointed at a page saying, “I think I have this”… looking down I could see that she was pointing at Myasthenia Gravis… the same diagnosis that I was sure she had… classic symptoms. My friday night would have to wait as I had to get this very sick lady taken care of… a couple hours later she was tucked in at University Hospital in Cleveland under the care of a different Neurologist and oddly enough I never saw her again. I understand she had an extensive/prolonged stay in the hospital but eventually did well and made it back home. That was definitely a case where the history made the diagnosis… and the patient literally told me what she had.

  • Doc99

    When doctors don’t know the answer, I suggest we call the Trial Lawyers for a consult. They always have the answer.

  • DVM

    >>That was definitely a case where the history made the diagnosis… and the patient literally told me what she had.>>

    I made a tough diagnosis yesterday after employing, in order, strategies #3&4 (patient improved temporarily but not 100%) strategy #1 (client was right… something wasn’t adding up), strategy #2 (it’s helpful to phone a friend… or two) and more strategy #1. The result? Diagnosis. Treatment. The patient is now improving. It’s a nice feeling.

    I thanked the client (and patient) for hanging in there with me.

  • http://twitter.com/ddwebster Dana

    Great post. I think more Americans need to understand that physicians are people, too, and the practice of Medicine is still as much an art as it is a science.

    I’m a big advocate for listening to that little voice inside your head. When I found a small, non-tender, non-fixed swollen supraclavicular node, my first physician (OB/GYN because I was 7 weeks postpartum) was “Not excited” about it and wanted me to return in a week. I went to my FP the next day who was a little more concerned because of the location of the node (left supraclavicular).

    The radiologist who did the ultrasound reported “Benign” adenopathy. My CBC showed only slightly elevated CRP levels (white cells were 7500). It took 3 pathologists to confirm Nodular Sclerosing Hodgkins.

    My instincts (and perhaps my background in Biology) told me something wasn’t right. If I’d been content with the OB/GYN’s opinion, I wouldn’t have been diagnosed as early. If I’d seen him a week later as he’d originally proposed, my node would not have changed. It didn’t grow in the 4 weeks from discovery to diagnosis. But, my cancer was already metastatic in the mediastinal, axilliary and supraclavicular regions bilaterally.

    I don’t blame my OB/GYN. I just didn’t think he was correct in his assessment, so I got other opinions. And, I’m glad I did.

  • http://thedoctorwriter.wordpress.com/ Leigh Ann Otte

    So many people complain, “My doctor said it was all in my head.” But sometimes it is. It must be difficult to determine which is which. Thank you for this interesting breakdown.

  • http://www.glycotrainer.com/glyconutrients/ glyconutrients

    I agree with Matt S’s statement “You have to be humble”. A lot of doctors will never acknowledge that they are in way over their head or that they don’t know what the problem is.

    This is a very interesting article. Many responses (comments) mention that doctors already use the web and some others suggest that MORE doctors should use the web. I think doctors should use all of the resources available.

    I think a lot of this behavior has to do w/ the fear of being sued, peer pressure, or pharma rep influences.

    Kevin :: Glyco Trainer
    On Twitter: @glycotrainer
    Web Site: http://www.GlycoTrainer.com