When you see your doctor, you want to know what’s wrong, follow the steps to recovery and get predictable results. Sadly, this is not always possible. Medicine is an art based on science that is constantly changing and full of things we don’t know.
Here are four reasons why it seems like your doctors didn’t get it right — when we actually did:
- Your symptoms or exam findings were not typical for your disease.
- The lab or other testing gave falsely normal or abnormal results.
- Your recovery was derailed by a complication that could not be prevented.
- Your disease progressed normally but you weren’t adequately prepared for what normal disease progression should be like.
Your body gave confusing signals
I have seen as many presentations of appendicitis as I have seen patients with appendicitis, because there are always differences in how each person experiences it. The exam can be variable and may not give me the right findings right away. The more atypical your disease presentation, the longer it may take to get to the right diagnosis. I may need more time, because some tests need to be scheduled for another day, like a colonoscopy, or a test may take several days for a result, like a Lyme titer, or your symptoms and exam may not progress to something more typical for that disease until hours or days later.
We got thrown off by testing results
Doing medical tests is like walking through a minefield. Tests lead us astray by either suggesting an abnormality when there isn’t one (false positive) or not identifying an abnormality when there is one (false negative).
False positive tests are more likely as we increase the number of tests we do. The “normal” values for any given test is based on what is considered normal for 95 percent of people. Your “abnormal” results may be normal for you. Sometimes we find things that have nothing to do with your illness (incidental findings). Some tests take time to come back, like urine cultures that need to be incubated for at least 24 hours. In order to get useful information now, we will do screening tests, like a urinalysis. If the urinalysis shows a possible UTI, but the urine culture doesn’t grow bacteria (false positive) — I may have given you antibiotics when you didn’t need them.
Sometimes we use multiple tests over time to identify your medical problem. For example, if your chest pain is due to a heart attack, your first electrocardiogram (EKG) can be fine (false negative), but a repeat EKG might not. The initial blood test (troponin) may be normal but then become abnormal hours after the heart muscle injury has occurred (false negative because of delayed rise in measurable troponin).
Sometimes, we can’t get all of the needed information immediately because of limited test availability, like stress tests. I need to take into account all of the information I can get now to come up with a recommended plan, knowing that this immediate information can be incomplete.
Ongoing research makes our understanding of disease — and how to use testing to diagnose disease — a moving target.
A complication derailed your recovery
Some complications we can warn you about, like allergic reactions, or take measures to avoid, like postoperative infections. Some are not predictable or avoidable, like amniotic fluid embolism, which causes catastrophic multi-system organ failure and death in pregnant women in labor.
Imagine you start an antibiotic for a urinary tract infection, and you develop a fever, rash and body aches. You’re diagnosed with a severe drug allergy called DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms), where your chances of full recovery are very good, but there is a known risk of organ failure and death. I could not have predicted this, although allergic reactions are possible every time I prescribe a new medication.
Imagine you get antibiotics for a UTI, and you wind up with a kidney infection because it turns out the bacteria was resistant to the antibiotic you were given. The test I can do right away to see if you have a UTI (urinalysis) is not as good as a urine culture, which takes a minimum 24 hours for a result. I have to use your symptoms, medical history, examination, urinalysis and local bacteria resistance patterns to make an educated guess as to whether you need an antibiotic and which one is the right one for you. Most of the time, that educated guess is right.
Your illness progressed normally, but you weren’t prepared for it
I haven’t done my job if I haven’t taught you what to expect (normal disease progression) and what to look out for (complications).
I often see patients in the ED on antibiotics for a skin infection (cellulitis) but are not getting better. It is normal for the redness, pain, and warmth of the skin affected by cellulitis to stay the same or even get a bit worse the first 24 hours after starting antibiotics, but the patient didn’t know this. In fact, it can take up to 72 hours to see a clear improvement!
Make sure you ask enough questions when you see your doctor to make sure you understand your problem, what the plan is what to expect and what to look out for — and why.
Being sick stinks. Not getting well as quickly as you expected is even worse. That’s not always because you got the wrong treatment. Sometimes it’s because modern medicine has limitations and human beings are complex. We can overcome many of these challenges by striving for good communication and working as a patient-doctor team.
Irene Tien is an emergency physician and can be reached at My Doctor Friend.
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