Thursday, April 03, 2014
Complexities of making diagnoses

By Dr. Anthony Policastro

Medical decision making is complicated. There are often multiple aspects to any one decision. Those aspects make decision making difficult. There are consequences associated with every possible decision whether it involves taking an action or not taking an action. Let me use appendicitis as an example. When a patient appears with abdominal pain, we need to decide whether the patient needs surgery for appendicitis. If we do the surgery and the patient has appendicitis, then we will cure the patient. If we do the surgery and the patient does not have appendicitis, then the patient has to recover from an unnecessary surgical procedure. If we decide not to do the surgery and the patient has appendicitis, then the patient will get worse. If we do not do the surgery and the patient does not have appendicitis, then we have done the right thing. It might sound like this is an easy decision. It is not. Most people would say that the worst thing that can happen is to not do the surgery and the patient will get worse. Therefore, we should do the surgery to be sure. The problem with doing it that way is that we will do a lot of unnecessary surgeries. We will have a lot of people who have to recover from surgery that did not need the surgery in the first place. We will increase the cost of medical care by doing too much surgery. Those are not good things. The result is that when someone appears with abdominal pain, we look at all the symptoms. We do some tests to help with the decision. When we are done, the information tells us that appendicitis is more likely or less likely. That allows us to do surgery on patients who are the most likely to have appendicitis. However, it also means that we are sometimes going to be wrong. There will be some patients that need surgery and do not get it because it does not look like they have appendicitis. There are others who will have surgery who did not need it. That is because their symptoms suggested that they did have appendicitis. Current diagnostic techniques help with the diagnosis. When I finished my residency, the diagnosis was sometimes very difficult. It was estimated that about 20% of patients who had surgery for appendicitis did not actually have it. The surgeon who had a lower rate than 20% was probably missing some cases. Even with the current diagnostic techniques, we still have to rely on clinical judgment. For example, I got a call from my daughter in South Carolina one night at 5 a.m. She told me that my granddaughter had bad abdominal pain. I asked some questions and I had her do some things. It was clear that she had appendicitis. I told her to take her to the emergency room. They told her that I was wrong. They were right for about four days. That was when she returned with a ruptured appendix. I saw a patient here in Seaford a few years back. She had been running a fever for two weeks. She had been seen by other physicians several times. She was 15-years-old. The rules of evaluating fever are that when you have a prolonged fever with no cause, you have to do a rectal exam. She had not yet had one. I did the exam and I felt a mass in the rectum. The CT scan confirmed an abscess from a ruptured appendix. She never really had abdominal pain. The bottom line is that decisions are not always easy to make. I will sometimes have someone tell me about a doctor missing a diagnosis.

Other times I will have someone tell me about a doctor making a diagnosis that proved to be wrong. In both cases, the individual will act like it should have been obvious which is often not true.  Physicians need to weigh all the information because we do not always have a clear cut picture. We do not want to do unnecessary treatments just to be sure. They carry their own set of complications.

If you have comments about this column or suggestions for other topics, send an email to Dr. Anthony Policastro at

Caregiver and Respite Conference April 30

Easter Seals Delaware & Marylands Eastern Shore, in partnership with the Division of Services for Aging and Adults with Physical Disabilities, will host the You Count! Dont Burn Out! Caregiver and Respite Conference on Wednesday, April 30, at the Easter Seals Conference Center in New Castle. There will be two sessions - morning for those caring for a child with a disability and afternoon for those caring for adults with a disability or seniors with aging conditions.  The cost to attend is $10. To register online, visit For more information, call Caitlin Gruber at 302-221-2087 or

Rachels Challenge The community is invited to hear the inspiring story of Rachel Joy Scott, a victim of the Columbine High School shooting in 1999, during Rachels Challenge, a bullying and violence abatement program, at 7 p.m. on Tuesday, April 8, at Phillis Wheatley Middle School in Bridgeville. Rachels Challenge will inspire others to replace acts of violence, bullying and negativity with acts of respect, kindness and compassion. This program is suitable for kids in 6th grade and up. For details visit

Parkinson support group The Parkinson Education and Support Group of Sussex County will hold its regularly scheduled monthly meeting from 1:30 to 3:30 p.m. on Monday, April 7, in The Lutheran Church of Our Savior, 20276 Bay Vista Rd., Rehoboth Beach. Note the new meeting time and location. The speaker will be neurologist, Dr. Lawrence Kemp. The public is invited to attend. Contact Dennis Leebel, 644-3465, for more information.

Photography For Wellness event The Cancer Support Community  Delaware will offer Art HOPE: Photography For Wellness at 5:30 p.m. on Thursday evening, April 10, at its Sussex facility. Pamela Montague, photographer and social worker, will engage with you to explore and recognize the benefits of photography. She will help you construct stationery to share with those you love, or to acknowledge support, inspiration, energy or guidance by sharing your personal vision and message through her collection of photographs called Sand Scripts. You can select from Pams inspiring photographs or bring your own photos to use. Call 645-9150 to reserve your spot for the session. For more information, visit