How early closure can cause doctors to misdiagnose

I had a patient once—a fellow physician—who came to see me complaining of mid-back pain.  When I examined him, I found I could reproduce his pain by pressing firmly on the spot he said was hurting him.  He said pressing there also made the pain radiate around to his stomach, a phenomenon known as “referred pain” that meant his pain was almost certainly caused by a trigger point.  I offered to inject it with a mixture of lidocaine and cortisone, a procedure that’s been shown in the medical literature to be helpful, but he declined, preferring instead to use over-the-counter pain relievers.

However, over the next few weeks, his pain intensified and began to interfere with his ability to work, so he arranged to have a CT of his chest and abdomen done at a nearby hospital.  He then called to tell me the CT had revealed a mass in his pancreas.  When the mass was removed a few weeks later, the pathology showed it to be an adencarcinoma of his pancreas.  Once he’d recovered from the post-operative pain, he told me the pain in his back was gone.

I’d never before encountered visceral pain masquerading so completely and convincingly as somatic pain (that is, pain from an internal organ behaving as though it was coming from a muscle).  Sometimes doctors gather all the clues correctly, think all the right things based on those clues, and still get it wrong.  But in this case, another significant thought error contributed to the misdiagnosis:  my tendency to come to early closure.

Early closure, it turns out, is a danger that lies in wait mostly for seasoned clinicians (far more commonly, at least, than for medical students and residents).  Because seasoned clinicians rely more on pattern recognition to make diagnoses and often come to their conclusions rapidly, they’re at far greater risk for leaping toward those conclusions without examining all other relevant possibilities.  Patients often present with a constellation of symptoms that don’t entirely fit the diagnosis they actually have.  Often the discrepancies between these presentations and the textbook descriptions are unimportant—but sometimes those discrepancies exist not because the patient’s body hasn’t read the textbook, but because the diagnosis the doctor makes is the wrong one.  Such misdiagnoses are occasionally unavoidable:  the symptoms with which the patient presents are simply too far afield from the way the medical literature says the disease should present (luckily for us all, this is the exception and not the rule).  At other times, however, these mistakes are made because the physician was simply in a hurry, or tired, or didn’t care enough to think through the evidence in ways he should have, saw a pattern he thought he recognized, and stopped asking the most important question a physician can ever ask:  what else could this be?

It’s the same with us all.  We all come to early closure all the time, forming opinions about the behavior of others without sufficient consideration of all relevant facts.  We become attached to the explanations that make the most sense from the perspective of our own experience and our own point of view.

But this frequently leads to misunderstandings, sometimes with disastrous consequences.  We so rarely seem to give others the benefit of the doubt, preferring instead to think the worst of them, especially when their actions produce inconveniences and difficulties for us.  But the path of true humanism is paved by dialogue, not assumption—by working to bring out the potential for good in others, not for evil.  Sometimes, in fact, it’s our own expectations that others will be good that brings out the good within them.  The real danger of early closure in the non-medical context, then, is that we all have a tendency to fulfill the expectations of others, and if others quickly assume the worst of us, we often deliver.

I apologized to my patient for missing his diagnosis.  He responded by telling me he’d agreed with my original diagnosis himself and had been floored when the CT had come back showing a pancreatic mass.  We both learned from our experience that day:  visceral pain can masquerade in some people as somatic pain.  Fool me once, I thought, shame on you.  Fool me twice, shame on me.

My patient forgave me readily, pointing out, quite correctly, that the modest delay in making the diagnosis would have no impact on the outcome whatsoever.  He was right:  six months after first coming to see me, he was dead.  And though my mistake didn’t cause his death, it remains in my memory a stark warning of the risks of failing to maintain humility when concluding a diagnosis is “obvious.”  I must remember that, though I’m usually right when I recognize a pattern, there will be times when I’m wrong.  And some of those times, being wrong will mean the difference between a patient’s life and his death.  Occasionally, that thought keeps me awake at night.  And I often wonder:  shouldn’t we worry about prejudging the motivations of others, too?

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.facebook.com/profile.php?id=1836009368 Paulo Tavares

    “Early closure” is also more or less progressively enforced by the non-medical part of the system — administrators and insurance companies.
    The “best” doctor is the doctor who spends less in exams!

  • Anonymous

    After having debilitating symptoms for 18 months with no meaningful progress with my PCP, I referred myself to a specialist.  After another year of working with this specialist, the original diagnosis was eliminated.

    When I returned to the care of a (different) primary care physician , the same wrong diagnosis was made again.

  • Joe Laughton Fields-Johnson

    Dr. Lickermann, I am sorry to hear of your missed diagnosis and the death of a colleague.  An interesting point is that may have made a correct diagnosis (trigger point with radiation) but it was not the primary lesion.  By treating that primary lesion with injection therapy or physical therapy the pain may have gone away temporarily (or not) but it would return very quckly because the pancreatic adenocarcinoma remained.  This would have been an idication to pursue another mechanism viserally (or somatically) for its cause.  This is one reason I am excited to be an Osteopathic medical student because we discuss cases just like this frequently, Visero-somatic, somato-somatic, psycho-somatic, and somato-visceral reflexes are quite frequent.  Your article reminds me that a thorough physical exam can help diagnose visceral lesions effectively.  I encourage you to contact an osteopathic physician who practices manipulation so you can learn more about this valuable tool.  Thank you for your writing.  Best, DO To Be

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