Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

How early closure can cause doctors to misdiagnose

Alex Lickerman, MD
Physician
August 12, 2011
365 Shares
Share
Tweet
Share

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.

Prev

Why doctors should stop wearing ties

August 12, 2011 Kevin 25
…
Next

MKSAP: 64-year-old man with abdominal bloating and epigastric discomfort

August 13, 2011 Kevin 2
…

Tagged as: Malpractice, Patients, Primary Care

Post navigation

< Previous Post
Why doctors should stop wearing ties
Next Post >
MKSAP: 64-year-old man with abdominal bloating and epigastric discomfort

More by Alex Lickerman, MD

  • The main difference between functional medicine and evidence-based medicine

    Alex Lickerman, MD
  • Is too much care as harmful as too little?

    Alex Lickerman, MD
  • a desk with keyboard and ipad with the kevinmd logo

    The art of compromising is the key to a healthy relationship

    Alex Lickerman, MD

More in Physician

  • Why allowing yourself to embrace discomfort is necessary for personal growth

    Jillian Rigert, MD, DMD
  • Unconventional health care, flawed studies, and biases: Navigating the complexities for optimal well-being

    Kara Wada, MD
  • Finding your ideal work-life balance: tips for prioritizing personal life and achieving professional success

    Zahid Awan, MD
  • Boxing legends Tyson and Foreman: powerful lessons for a resilient and evolving health care future

    Harvey Castro, MD, MBA
  • 7 ways to beat burnout: a guide for health care professionals to reduce stress and reclaim their passion

    Marie Livesey, DO
  • Heartwarming stories of cancer patients teaching us about life and the human spirit

    Johnathan Yao, MD, MPH
  • Most Popular

  • Past Week

    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Why affirmative action is crucial for health equity and social justice in medicine

      Katrina Gipson, MD, MPH | Policy
    • Unlocking the secrets of cancer conferences: an end-of-life counselor’s journey among pharmaceutical giants

      Althea Halchuck, EJD | Conditions
    • Why doctors aren’t to blame for the U.S. opioid crisis [PODCAST]

      The Podcast by KevinMD | Podcast
    • Nose-brain connection: The surprising link between allergies and mental health revealed

      Kara Wada, MD | Conditions
  • Past 6 Months

    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
  • Recent Posts

    • Why allowing yourself to embrace discomfort is necessary for personal growth

      Jillian Rigert, MD, DMD | Physician
    • Unconventional health care, flawed studies, and biases: Navigating the complexities for optimal well-being

      Kara Wada, MD | Physician
    • Urgent innovation needed to address growing mental health crisis among children and families

      Monika Roots, MD | Conditions
    • The importance of listening in health care: a mother’s journey advocating for children with chronic Lyme disease

      Cheryl Lazarus | Conditions
    • Medical errors and the power of apologies [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding your ideal work-life balance: tips for prioritizing personal life and achieving professional success

      Zahid Awan, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • FDA Warns on Certain Forms of Compounded Semaglutide
  • Fired COVID Whistleblower Doesn't Want to Settle His Case
  • Video of ACOG Presenter Being Slapped Goes Viral
  • Bed Bug Anaphylaxis; Heart Block Relationships; What's It Like to Date a Nurse?
  • TAR-200 Led to High Complete Response Rates in BCG-Unresponsive Bladder Cancer

Meeting Coverage

  • TAR-200 Led to High Complete Response Rates in BCG-Unresponsive Bladder Cancer
  • More Success for CAR T-Cell Therapy in Rheumatic Disease
  • Trial Shows RA Can Be Stopped at Preclinical Stage
  • Tenapanor Improves Abdominal Symptoms in Patients With IBS-C
  • Benefits Found for Hand OA Drug Treatments
  • Most Popular

  • Past Week

    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Why affirmative action is crucial for health equity and social justice in medicine

      Katrina Gipson, MD, MPH | Policy
    • Unlocking the secrets of cancer conferences: an end-of-life counselor’s journey among pharmaceutical giants

      Althea Halchuck, EJD | Conditions
    • Why doctors aren’t to blame for the U.S. opioid crisis [PODCAST]

      The Podcast by KevinMD | Podcast
    • Nose-brain connection: The surprising link between allergies and mental health revealed

      Kara Wada, MD | Conditions
  • Past 6 Months

    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
  • Recent Posts

    • Why allowing yourself to embrace discomfort is necessary for personal growth

      Jillian Rigert, MD, DMD | Physician
    • Unconventional health care, flawed studies, and biases: Navigating the complexities for optimal well-being

      Kara Wada, MD | Physician
    • Urgent innovation needed to address growing mental health crisis among children and families

      Monika Roots, MD | Conditions
    • The importance of listening in health care: a mother’s journey advocating for children with chronic Lyme disease

      Cheryl Lazarus | Conditions
    • Medical errors and the power of apologies [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding your ideal work-life balance: tips for prioritizing personal life and achieving professional success

      Zahid Awan, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

How early closure can cause doctors to misdiagnose
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...