When doctors can’t figure out what’s wrong with a patient

Part one of a series.

The first patient I ever saw as a first year resident came in with a litany of complaints, not one of which I remember today except for one—he had headaches. The reason I remember he had headaches isn’t because I spent so much time discussing them but rather the opposite: at the time I knew next to nothing about headaches and somehow managed to end the visit without ever addressing his at all, even though they were the primary reason he’d come to see me.

Then I rotated on a neurology service and actually learned quite a lot about headaches. Then when my patient came back to see me a few months later, I distinctly remember at that point not only being interested in his headaches but actually being excited to discuss them.

I often find myself thinking back to that experience when I’m confronted with a patient who has a complaint I can’t figure out, and I thought it would be useful to describe the various reactions doctors have to patients in general when they can’t figure out what’s wrong, why they have those reactions, and what you can do as a patient to improve your chances in such situations of getting good care.

The scientific method
Believing a wacky idea isn’t wacky in and of itself. Believing a wacky idea without proof, however, most certainly is. Likewise, disbelieving sensible ideas without disproving them when they’re disprovable is wacky as well. Unfortunately, patients are often guilty of the first thought error (“My diarrhea is caused by a brain tumor”) and doctors of the second (“brain tumors don’t cause diarrhea, so you can’t have a brain tumor”), leading in both instances to contentious doctor-patient relationships, missed diagnoses, and unnecessary suffering.

Doctors sometimes aren’t willing to order tests that patients think are necessary because they think the patient’s belief about what’s wrong is wacky; they sometimes suggest a patient’s symptoms are psychosomatic when every test they run is negative but the symptoms persist; and they sometimes offer explanations for symptoms the patient finds improbable but refuse to pursue the cause of the symptoms any further.

Sometimes these judgments are correct and sometimes they’re not—but the experience of being on the receiving end of them is always frustrating for patients. However, given that your doctor has medical training and you don’t, the best you can sensibly hope for are judgments based on sound scientific reasoning rather than unconscious bias. Unfortunately, though, even the minds of the most rational scientists are teeming with unconscious biases. So a more realistic strategy might be to attempt to leverage your doctor’s biases in your favor.

Expert versus novice thinking
In order to do this, you first need to know how doctors are trained to think. Medical students typically employ what’s called “novice” thinking when trying to figure out a diagnosis. They run through the entire list of everything known to cause the patient’s first symptom, then a second list of everything known to cause the patient’s second symptom, and so on. Then they look to see which diagnoses appear on all their lists and that new list becomes their list of “differential diagnoses.” It’s a cumbersome but powerful technique, its name notwithstanding.

A seasoned attending physician, on the other hand, typically employs “expert” thinking, defined as thinking that relies on pattern recognition. I’ve seen carpal tunnel syndrome so many times I could diagnose it in my sleep—but only learned to recognize the pattern of finger tingling in the first, second, and third digits, pain, and weakness occurring most commonly at night by my initial use of “novice” thinking. The main risk of relying on “expert” thinking is early closure—that is, of ceasing to consider what else might be causing a patient’s symptoms because the pattern seems so abundantly clear. Luckily, in most cases, it is clear.

But sometimes it isn’t.

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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  • http://www.insweb.com Robert

    Sometimes I visit the doctor with a litany of complaints, but they all just come down to one ailment. I think it’s up to the patient, too, to emphasize what’s bothering them most so the doctor can make an accurate diagnosis. Throwing the kitchen sink at a doctor won’t help anyone.

  • Abandoned

    I have an undiagnosed chronic health issue. I have been blamed, ignored, misdiagnosed, mistreated, passed around….

    Without a diagnosis, there is no discussion on quality of life, reducing symptoms, or compassion. I suffer alone.

    • Laura

      “Without a diagnosis, there is no discussion on quality of life, reducing symptoms, or compassion. I suffer alone.”

      Wow, I’ve never thought about that, but it is so true! Without a diagnosis, you are “nobody.”

    • Sherry

      You are not alone. My uncle has lost half his body weight, puked up 2/3 of his blood, vomitted daily, in pain all the time, has no strength, etc. and he has been to a mulitude of doctors and NO ONE knows what is wrong with him. They just give him more pain pills (that don’t work) and send him home everytime! We don’t know what else to do, we are just watching him die and no one is helping.

  • Jonas

    I was in Shanghai and speaking to a old traditional Chinese Medicine Doctor. He said “When a chinese doctor sees a patient, he sits them down, listen to their pulse, observe their eyes, tongue, skin, and then we tell them what is wrong with them; Western doctors have an easy job – you sit down and they ask you ‘What’s wrong with you?””

  • stargirl65

    I agree that expert thinking can take you down the wrong road sometimes. But usually you can tell when things aren’t right, or typical, for where you are going. I will convey this to the patient such as, “You symptoms seem most consistent with carpal tunnel syndrome but do not entirely match carpal tunnel syndrome. We will treat you for carpal tunnel syndrome and if you do not improve then we will rethink things.” Patients usually seem OK with this.

    Unfortunately, medical problems do not present with concrete, obvious symptoms 100% of the time. Also, there are many illnesses and diseases that have not yet been discovered or figured out. These times are when both doctor and patient become frustrated.

  • Laura

    I suffered with a chronic illness for 15 years. I came to realize that if the answer was not in the doctor’s head, the problem was in the patient’s.

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