A doctor's view on diagnosis

I'm a family doctor. I worked for the past 6 years with one mid-level provider in a small office in an urban setting in New Jersey.

John was a patient I met soon after starting in my office. I saw his whole family, including his 6 children, his girlfriend and a sister. John was in his late 30's, generally healthy with only the occasional cold and mild, diet controlled high blood pressure. He was tall and thin, friendly, talkative. Honestly, I saw him more for his childrens' routine visits than for himself.

About a year later, John came in complaining of mild weakness in his left leg. After thoroughly examining him, concentrating on any neurological signs and symptoms, I called the oldest, most experienced neurologist in my health system, Dr. M. He and I agreed upon blood and imaging tests.

John and I agreed on the plan: we'd meet in the next week to review the results of all the testing. I had scheduled Dr. M's first available appointment which was in 6 weeks. This would be used either to confirm the diagnosis and continue or start treatment or to continue the workup if the first tests didn't lead to definitive diagnosis.

I was worried about multiple sclerosis.

The tests were all perfectly normal. John saw Dr. M, whose further testing was all normal. Dr. M sent John back to me. John's left leg got worse and his right leg became symptomatic. I sent him back to Dr. M. Dr. M repeated tests, failed to find any abnormalities and sent him back to me. I began to see John once a week. I took an hour (4 patient visits) to redo a complete history and physical. John saw 3 other neurologists, including a renowned physician at the University of Pennsylvania. Except for one, all doctors repeated the MRI at their institution. All physicians reported back that John was healthy - one suggested a psychiatrist.

I was beginning to dread our weekly meetings. My practice was thriving. Being a Spanish speaking female in an underserved, predominantly hispanic area, I was seeing 25-30 patients a day and working straight through my "lunch" and well into the evenings when I should have been home with my children. I was really busy. John would sit on the table and I would look over new MRIs and neurological tests I'd only heard of in medical school. I had nothing new to report. I couldn't be reassuring. I searched every resource I had. I called my residency faculty neurologists. I called the renowned physician to pick his brain (we never were able to speak, despite my numerous attempts.) I got curbside consultations at every Grand Rounds I attended. I was beginning to resent John. I wondered what he thought of my abilities as a doctor. As a person.

The vast majority of the typical family doctors' patients are accurately diagnosed instantaneously. I have taught medical students for years. One of the clinical skills that every student of mine hones is the process of creating a differential diagnosis based on the patient's age, gender, past medical history and chief complaint before even entering the room. Asthma exacerbation, diabetes, viral infection, hypertension, skin infection, vaginal infections, heart failure. These are the 'bread and butter' diagnoses we live and breathe.

Then there are the diagnoses we make after 2 visits, after waiting for some blood results or imaging studies. These are straightforward enough as well: renal failure, some heart failures, high cholesterol.

There are also some less common illnesses that take some creativity, the ability to see the whole picture, or the help of a specialist, but most of these patients return for management after only one or two visits with other physicians.

So, what was I to make of John? What was he supposed to do? I left my practice this past August when I moved to California. John still had no diagnosis. He walked with a cane, but at least his symptoms had stabilized. One of the neurologists had begun treatment for MS, although still refusing to formally give him the diagnosis due to lack of criteria.

As I think back on my thousands of patients, John was one of my most frustrating, disappointing encounters. I think this is because I, like many doctors, thrive on helping people. My pay is another person's relief, gratitude, happiness. Ultimately, I only superficially provided some of that for John because I care. I failed to truly help because I was unable to help him secure a diagnosis. Even if I could have facilitated finding the doctor who could have diagnosed him, that would have been success.

As doctors, we tend to diagnosis quickly and concentrate more on the details of treatment. Many of us see this as the interesting and rewarding part. But as I think back on cases like John's, I realize that diagnosis can be quite elusive. When you think about it, it can turn into the limiting factor to pursuing treatment. I do believe that we need better tools for complex diagnostic cases.

Health 2.0 tools are fostering great connections between individuals in health care. Nonetheless, most of these tools are focused on treatment and disease management. It's time we use them to help solve these diagnostic challenges.