when to reconsider a diagnosis

Karen Cosby kcosby40 at GMAIL.COM
Mon Jan 20 22:51:34 UTC 2014

Why aren't you willing to tell the first physician?  Physicians can't learn
from the experience, or come to recognize a some conditions unless they get
feedback.  Most of us want to be correct, and we want feedback if we
aren't.  A Big problem I see is patients switching doctors whenever they
don't think the diagnosis is correct, rather than returning to the original
with new evidence or new information.  I saw a patient this week in the ED
who had been admitted to 2 different academic teaching hospitals with
extensive workups who came to the ED because they didn't have a diagnosis
established. (And they came without copies of any of their tests or
imaging).  Whenever patients switch doctors, most doctors begin all over
again with the same point rather than build on prior work-- inevitably
arriving at the same conclusion.  If we don't know what's been done before,
we can't make progress beyond what's already been done.  We need to explain
that diagnosis is an iterative process.  We typically begin to workup what
is most dangerous, things that need to be ruled out to be safe, and common
things.  Only after that do we consider unusual causes or less common or
more chronic conditions.  It's not necessarily wrong to take time to
establish the diagnosis, especially if it's not emergent or common.  We
should all be lucky enough to arrive at the correct diagnosis in a single
visit, as if endowed by some special power.  Instead, we sometimes have to
plod along hopefully with some thoughtful and considered process.  Part of
the problem isn't always that doctors don't try or aren't informed; some of
this is a failure to establish trust and communicate the process necessary
to make a diagnosis.

On Mon, Jan 20, 2014 at 3:56 PM, Vic Nicholls <nichollsvi2 at gmail.com> wrote:

> Dr. Gordon,
> Quite an excellent point. One question for the MD's: how long before a
> treatment doesn't work are you willing to consider something else? This was
> a problem I had. The doctor told me to keep taking these pills, just take
> more of them. The side effects were an issue. I self referred to a
> specialist and we got the ball rolling. We fixed one problem and proved
> that there is another underlying problem (the one I said was the issue all
> along). I never told the original doctor. I will thru his admin though.
> After 6-7 months of not improving, I was fed up. How do you all deal with
> this issue?
> Victoria
>  On 1/20/2014 12:54 PM, David Gordon, M.D. wrote:
>>> Bob,
>>> This may be different for chronic complaints or symptoms that have
>>> defied diagnosis despite repeat health care visits. In that scenario, I do
>>> believe that patients pursuing their own research and forcing physicians to
>>> consider diagnoses that haven't been considered or reconsider diagnoses
>>> perhaps too easily dismissed could be important.
>>> -David
>>> David Gordon, MD
>>> Associate Professor
>>> Undergraduate Education Director
>>> Division of Emergency Medicine
>>> Duke University
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
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