How doctors (don’t) think

My last few posts have stimulated quite a response. What is a surprise is how much criticism I received for suggesting that physicians consider other explanations of symptoms beyond only the thyroid. I feel this way about every diagnosis being considered.

Before I became an endocrinologist, I practiced for several years as a general internist. I soon became disillusioned. Primary care physicians are expected to know everything and do everything — all in 15 minutes or less. If you are unable or unwilling to see 25 or more patients in a day, you may be loved by your patients, but administrators will often think of you as less effective.

A gastroenterologist friend told me, “Why become an endocrinologist? In medicine, we’re paid to do, not to think!” He was right. However, I enjoy thinking, and I hate missing things. I love being able to spend the necessary time with my patients. Both they and my peers appreciate my attention to detail.

I always consider the entire differential of possible diagnoses. I ask why and what. Why does this patient have these symptoms? Why have they not responded to treatment? What else could we be missing? The answer often lies with the patient. Unfortunately, it takes less time and effort to prescribe a medication or order an imaging or laboratory study than it does to ask questions and think.

I have made many diagnoses by looking further into problems. There were the patients diagnosed with irritable bowel syndrome who had celiac, the patients with fibromyalgia who actually had severe vitamin D deficiency and the men with hypogonadism who also had hemochromatosis.

Then there was the woman who had “bubbles in my leg.” Her primary care physician warned me that she was “nice but a little nutty.” She had hypothyroidism but did not have any complaints related to that. Her main concern was that, for the last three years, “I feel bubbles moving in my leg!” Unsure of what to say, I examined her. The area of concern, her upper left thigh did feel a bit softer than the right.

Puzzled, I listened with my stethoscope. Amazingly, I heard bowel sounds! I wonder what another physician would have thought if they observed me intently listening to this woman’s leg. “He’s nice but a little nutty,” perhaps? She had herniated some of her abdominal contents into her thigh after a car accident three years earlier. Her symptoms were so bizarre that no one had taken them seriously. Surgery went well; her recovery was uneventful.

I have had my share of missed diagnoses too. Most of these happened because I was rushed and made a snap judgment based on my initial impression. It’s an easy trap to fall into.

An excellent book about this issue is “How Doctors Think,” by Jerome Groopman, MD. I recommend it highly to both patients and physicians. It should be required reading for all medical students.

If some find fault in my approach, so be it. There are worse things to be accused of than being thorough and asking why.