Sunday, September 11, 2011

Uncertainty hard for doctor and patient

Inside Medicine: Uncertainty hard for doctor and patient

By Michael Wilkes

Published: Sunday, Sep. 11, 2011 - 12:00 am | Page 14I
I take care of a young woman, Brenda, who has had chronic pain for the
past six years – since she was 14.

At this point, I am stumped. I have no idea what is causing her pain and
neither do the nine experts I have consulted with at various medical centers.

While Brenda is a delightful and smart woman, she is also the type of
patient most doctors dread caring for. She has so many symptoms it is hard to
keep track of them all, and they don't fit together in a nice tidy diagnostic
package – like pancreatitis, or ovarian cysts, or bone cancer.

She can't be diagnosed in a standard 11-minute doctor-patient appointment –
or even dozens of 11-minute appointments.

Our lack of certainty about her diagnosis and our inability to provide a
prognosis or effective treatments have led her to be a target for more
unscrupulous doctors who act as if they know exactly what is going on. They
offer her a clear diagnosis, often with a fancy Latin name.

The doctors then suggest a zillion laboratory tests, most of which have not
been shown to be helpful.

Finally they offer Brenda one or another unproven treatment that promises
her a false hope but predictably earns the treating doctors great profits.

One thing is certain, Brenda is greatly disabled by her pain – to the point
that she can not engage in meaningful work or academic studies.

Nonetheless, many doctors end their visit by suggesting her disease is
psychosomatic or even fictitious. Rarely do they want to continue to see her.

The truth is they simply can find no other explanation for her symptoms and
they can't handle uncertainty. If we can't understand or find it, then it
must not exist.

The thinking goes something like this: I am a good doctor and I have taken
a good history and ordered all the appropriate laboratory tests.

Since I can find nothing wrong with Brenda it can only be that she is
imagining this pain or the pain is providing her some other benefit that keeps
it going.

But Brenda still hurts. To her, the pain is very real and she takes those
comments from doctors as though they don't believe her. Now she and her
parents are growing angry at the medical profession and impatient – and scared.
Are the doctors missing something serious?

Frankly, as her doctor, I don't know if we are missing anything, and I am
out of experts to ask. At this point the dose of her narcotic pain killer is
so large it would render unconscious an average football player, but the
medicine is the only way she can find some comfort – at least until the dose
wears off.

As I lie awake at night wondering if I am missing something important, or
overtreating her pain, my thoughts move to Brenda, who must also be awake
thinking about the doctors who don't believe her and are resistant to provide
her with the only medicines she knows will work: narcotics.

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