04 Aug Second Opinions and the Pitfalls of Diagnosis
Medicine can be a tricky pastime for patients as they seek a diagnosis. Lots of long words, overlapping conditions, conflicting opinions and advice.
One of the best tools for untangling these situations and coming to a useful diagnosis is time. Time spent with a practitioner can help understand what is going on and help a patient make the right decisions. After all, we are always told that the backbone of a diagnosis is in the patient history. More time means more story-telling, and invariably, the answer is found.
Let’s look at a scenario, and then see what’s perhaps gone wrong.
A Story We Typically Hear
A patient walks into their GP’s office. They have pain in their back, and also into one of their legs. The GP thinks, “Bingo! This sounds like sciatica. Wasn’t that easy?!”. They duly respond by prescribing some strong painkillers and anti-inflammatories. Sciatica is typically very painful, and that’s what’s needed to treat that diagnosis!
They might also order an MRI, especially if the patient isn’t at all better a week or two later. A lot of cases of sciatica can be traced back to a disc injury, but it can also be caused by other issues. MRIs can help differentiate what is going on in non-resolving cases.
However, the patient might not have sciatica!
Sciatica is NOT the only thing that sends pain to a patient’s leg! It might be a joint in their back, a joint in their pelvis, or it might even be a muscle that’s unhappy. (See our Three Rs blog for more about this).
Importantly, none of these issues particularly require an MRI, but it’s not too long before our patient is sat reading an MRI report listing all the niggly things that are less than perfect in their spine.
They’ve also been taking the strong medications prescribed by the GP for a few weeks and putting up with the (often unpleasant) side effects.
They’re getting worried as they think about the damage seen in their MRI and what it means for them and their future. Meantime, the pain isn’t improving, and they start to think more negatively, even starting to panic. It affects their relationships, their work, their hobbies.
Is There a Different Way?
Some patients decide to come to a clinic like ours. We spend longer listening to their story, perform a more detailed examination and listen to the patient’s concerns regarding their MRI and anything else they’ve read or been told.
We often find a different diagnosis for their symptoms, give them some education and reassurance, and start working to get them better. A few sessions later things are under control – perhaps not 100% pain-free, but a corner has been turned.
What Have We Done Differently?
We have listened to the whole story and avoided the pitfalls of assuming the patient has the first thing that comes to mind. With all respect to GPs, our musculoskeletal training is much more detailed. While it’s always comforting that a GP is satisfied a patient’s problem is indeed musculoskeletal (not a diagnosis related to infection or other illness), we feel that at this point the baton should be passed to us! If only the NHS had the foresight to have musculoskeletal practitioners stationed in every doctor’s surgery! We’ll leave that for another day…
The issue here is what is referred to as pattern recognition.
Sure, as you gain experience in a field such as medicine, you often need less time to form a diagnosis. You see a set of conditions over and over again, and you develop the ability to spot it as soon as the patient walks into the room.
However, relying solely on this method as a way of diagnosing patients leaves us open to making mistakes. Sure, a patient with low back and leg pain might have sciatica, but they might also have something completely different. They might have lateral elbow pain and fit the criteria for tennis elbow, but they might not actually have that specific condition!
How to Avoid Mistakes
The way to avoid these pitfalls is to ask more questions, be more inquisitive, and avoid the traps. It might not mean asking about every little detail, but it does mean asking enough to be sure about what is going on and performing an examination that teases the options apart. This all takes time, and that’s what we have more of for our patients.
It might even be the case that a patient’s complaint is in fact not being caused by a mechanical injury, but by some other underlying condition. For example, shoulder pain can be a referral from an inflamed gallbladder, or back pain referred from a kidney problem. Only with time and questioning can these masqueraders be uncovered and duly tackled.
Before we’re done, there’s one more issue worth discussing.
The term “false positive” refers to when a test or examination reveals something that is perhaps not the real cause of a patient’s pain or dysfunction.
For example, our patient above who was sent for a low back MRI might get given a report that notes a disc herniation or bulge in his low back. At this point, everyone might think “case closed”. They believe that the disc injury is the cause of all the pain and duly form their diagnosis and direct treatment accordingly.
But what if that bulge was there before the onset of this episode of pain?
There are findings like this on MRIs on an awful lot of people without any low back pain, so there’s a very real risk that it’s not the cause of the current pain! Ideally, an MRI from before the pain started would prove this right or wrong, but this is rarely available!
So not everything on an MRI can be assumed to be the root of the problem. This is the difference between correlation and causation. Lots of people with low back pain might have the correlation of an MRI displaying disc degeneration, but it doesn’t mean that any disc degeneration is causing their pain.
We hope that this blog is helpful, but you might now be more confused!
This is why a second opinion might be useful.
Having time with a new practitioner, with whom you can tell the whole story and have the available evidence appraised might be enough to help you make a decision that you feel has your best interests at heart.