Missed Diagnosis

So, I finally did it. I correctly diagnosed a previously-missed diagnosis. I’ve found that most of the time when a doc talks about catching something all the other super-smart docs missed, they have some sort of ax to grind. Most commonly – and not to start a war about the merits of chiropractic – I’ve heard it from chiropractors. I even heard one talk about how he correctly diagnosed herpes zoster after the patient had seen two other specialists.

Sometimes, like with the chiro guy, I don’t believe the stories. Mostly, though, I don’t believe in myself enough to think that I could catch something these other incredibly smart docs miss. I remember my med school class. Those people were SHARP. I watched them evaluate and diagnose patients every day. It never seemed like they missed a THING while I was always bumbling around trying to untangle myself from the IV tubing. Now, in residency, I’m a little less in touch with my colleagues, but they all seem so infallibly competent as well. I trust most of them implicitly. This is doubly true of the docs who are working and practicing in the community. These are full-fledged doctors. How could I ever do it better than them?

But I did. It wasn’t because I was smarter or better. The diagnosis was simple. If anything, I picked up what others missed just by listening to the story. Maybe everyone else was rushed when they saw this patient. They all got into highly competitive residencies and ostensibly know more medicine than me. But somehow, four doctors mis-diagnosed this patient. I knew his problem within 10 minutes.

The patient is a middle-aged male who came in saying he had an appointment with a specialist (a urologist) because he’s been having severe pelvic pain for the past 2 weeks. Come to think of it, it’s actually been much longer than that, but the past 2 weeks it’s been really bad. He was seen by two doctors in an urgent care clinic, who first gave him antibiotics and told him he had an infected prostate (in spite of a perfectly normal UA), and then gave him pain meds and told him to go to the ER if things got worse. Then he went to our vaunted ER, and was also told he had prostatitis and maybe prostate cancer and that he needed to see a specialist.

Sitting my office, he says he “hates doctors” (greaat, nice to meet you too) and hasn’t seen one since he was 12. He’s one of those tougher-than wood kinda guys that has worked in construction since the trade was invented. And I notice that he’s near tears. It’s the cancer bit, I figure. Works every time. I don’t know why docs throw that out there when they have no evidence. So now this guy is sitting on the exam table, visibly shaking, taking deep breaths and scared to death. I’m thinking that it would be easier to make a slab of drywall cry than to make a guy like this emotional, so I know he’s about a low at he gets.

None of his symptoms sound like prostatitis. Or a UTI, which is pretty rare in males anyway. The pain argues against cancer. Few people this upset are mere drug-seekers, and he isn’t asking for drugs anyway (although seekers use this tack frequently too). “Let me see this famed abdomen,” I say. I already have an idea that he simply has hernias. Sure enough, one quick check and it’s abundantly clear he has bilateral, indirect inguinal hernias. A med student coulda made that diagnosis. I think HE thought it was hernias. But both he and I figured we must be wrong because all these brilliant, well-trained docs said it was something else.

“Nobody’s actually done that exam thing on me,” He said as I took off my glove. “They always just jammed a finger up my butt. Don’t you need to do that too? I HATE the finger thing.”

“I hate that test too” I said (just read my blog about it, I think sardonically) “But I’d do it if I thought you needed it…and you don’t. You have hernias and if you go see that urologist, whatever doc referred you there is going to be pretty embarrassed. Cancel the appointment. Today. You don’t have cancer, either. It’s a simple surgical problem; you’ll be out of the hospital the same day.”

He couldn’t believe it. “REALLY?” He says. We look at each other in perfect understanding. I’m not offended by his suspicion. I’m this punk family medicine resident, not even out of training yet. I ride a skateboard to work, my hair’s never combed and I’m rarely on time. I went to school in Israel as a ploy to make global traveling look legitimate. Who am I to contradict wiser heads than mine?

“Man, I’m telling you. I’m dead-on. It’s hernias.” It felt good, strong, to say that. Even if it was only hernias.

Yesterday, I saw the guy again. Surgery is done. He’s all wide-eyed and looking at me like I’m brilliant. Says he told everyone in the ER (went back there while waiting for surgery because the pain got so bad, and got the surgery emergently that night) that I was the only doc in town who got the diagnosis right. I’m sure the ER doc loved hearing THAT. In truth, I made an elementary diagnosis partly because other stuff had been ruled out and partly because I had the time and wherewithal to really listen to the guy’s story. I think that’s why there’s more than one doc on this planet, and why there’s such a thing as second opinions. None of us gets it right every time, which is why I hate medical litigation. We’re all just human. I don’t even want to THINK about how many times my colleagues have picked up the fragmented pieces of my near-misses and forged them into a good outcome for my patients. But, for once, it was gratifying to be the guy who picked up the pieces. To make things right. This patient thinks I’m a hero. I figure it was just my turn…and it sure was fun.

2 thoughts on “Missed Diagnosis

  1. kevinthomas

    Well LA DI FRICKIN DA! Look who made the dean’s list!

    No but really, congrats. I’ve had a couple great experiences lately with doctors really listening and trying to put the pieces together and I’m very grateful for it.



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