Thursday, August 26th. 1999
Diagnosing symptoms not always that clear cut

By Dr. Anthony Policastro
Nanticoke Memorial Hospital

Medical students have many things to learn. One of those is something called differential diagnosis. This means that many diseases have the same symptoms. Therefore, it is important to sort through the symptoms to figure out the correct diagnosis. This is not always easy. On Star Trek, Dr. McCoy had a device that he ran over the patient’s body. It always made the correct diagnosis for him. Sometimes patients think that all physicians can do the same thing. For example, I once admitted three patients in a single night when I was an intern.One had a high fever and a rash. One had a high fever and joint problems. One had joint problems and a rash. The stories wee very similar. The physical exams were very similar. The lab tests we ordered were very similar. The results of those tests were very similar. The following morning, I had to present the three patients to the senior staff physician. I was expected to do it without notes. You can imagine the confusion in the three presentations. It didn’t help any to have been up all night doing the admissions. Our technology has certainly changed over the years. Laboratory testing has changed over the years. However, the fact that patients do not always show up with a clear-cut diagnosis has not changed. Unfortunately, patient expectations have changed greatly. The result is an expectation that the correct diagnosis will be made 100 percent of the time. This is not possible. But, it is certainly expected. The Wall Street Journal had an article on March 31, 1999. It discussed the fact that in the old days the physician did not often make the diagnosis. If he/she did, the condition often could not be treated. However, the patients were grateful that the physician did his/her best. The expectations were based upon the realization that often nothing more could be done. The article also pointed out that it was not until 1930 that a visit to the doctor was more likely to benefit the patient rather than damage him/her. I often see patients complain because their expectation for the success of modern diagnostic techniques was 100 percent accuracy in diagnosis. It does not work that way. There are two areas where this is particularly true. One of those is the emergency department (ED). I frequently get to answer complaints about the ED. One of the most common complaints is that the ED did not make the correct diagnosis. The idea behind the ED is to make sure a patient does not have a serious diagnosis. The correct diagnosis is not as important as not sending the patient out with something that could be fatal. The last time I was on call, one of the ED physicians called me. He said that he had a child that did not look quite right. He did not have a diagnosis. However, he did not think the child was well enough to go home. I went to see the child. The symptoms were indeed puzzling. As we tried to put the pieces together, the five-year-old brother finally indicated that he had sprayed his younger brother with “Off” bug spray. The ED physician did not make the diagnosis. However, he did make the right call as to the seriousness of the problem.
That is how it should work. Some patients go to the ED with abdominal pain. The symptoms do not always fit a certain pattern. If a patient arrives with lower right-sided abdominal pain and tenderness when the area is pushed on, fever between 100-101 degrees, vomiting, loss of appetite, high blood count, pain with walking, pain with hitting the heel of the right foot, poor intestinal sounds and pain in the right side when the left side is pushed on, the diagnosis of appendicitis may be clear. However, very few patients have all these symptoms. Some have only one or two of them. Therefore, the diagnosis of appendicitis is difficult. There is only one way to make the diagnosis 100 percent of the time. That is to operate on everyone that shows up in the ED with abdominal pain. That makes no sense. The same kind of thing is true with other diagnoses. Sometimes it is very clear. Sometimes it is not. When the diagnosis is not clear, the physician must decide what is most likely. It is impossible to be correct every time. Patients should understand that.

High expectations for fatal conditions

The other area for which there are high expectations are fatal conditions. People often expect that cancer will be diagnosed early enough to cure it. This is true even when they wait for a long time before seeking help for their symptoms. I had three wives complain to me when I was in the Air Force. In each case their husband was a heavy cigarette smoker. In each case their husband had developed some respiratory symptoms and was treated for a cold. The cold did not improve and a Chest X-Ray was done. The X-Ray showed lung cancer. The wives were upset that the X-Ray was not done when the husbands first came in with the cold. Of course even if it had been done at that point, it would not have mattered. Once lung cancer is big enough to show up on X-Ray, it is too late to cure the patient anyway. However, the failure to diagnose the cancer in time was the physician’s fault. The years of cigarette smoking were not relevant. Medical science should have done better. Other people expect that when cancer is diagnosed, the physicians should always be able to cure it. Sometimes that happens. Sometimes it does not. The cancer decides which of the two things happens. Medical science does not control that. There are other fatal diseases besides cancer. Again the expectation is that physicians will diagnose these every time. The expectation is that physicians will treat them successfully every time. If a patient dies, then the physician must have done something wrong. In order to meet these expectations, physicians would have to ensure that everybody lived forever. We all know that immortality is not possible. It is just that we want to put it off as long as possible. We want the correct diagnosis even when the symptoms do not clearly suggest one. We want a successful treatment even when one does not always exist. There are limitations to what can be done. I would love to have one of Dr. McCoy’s devices. Unfortunately, it will not happen in my lifetime. Or else, it might if we can get all the diagnoses and treatments right and make me immortal.