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Wednesday, October 3, 2007

Post#4 Did My Doctor Miss the Diagnosis?

Every so often, I will walk into an exam room to meet a new patient who has come to elicit a second opinion. Many will readily explain what they are concerned about, who their primary doctor is, what they were told, why they are worried and for what they are seeking a second opinion. Others will tread more lightly, offering vague clues as to why they are seeking a second opinion - either they are slightly embarrassed to second guess their doctor, or they fear that too many facts will bias my mind, thus tainting the objective second opinion they seek.

There have been a few times, after listening to a parent's story and examining them, it seems clear that the previous doctor did not accurately diagnose or work-up the patient before me. I use the word "seems" because there are two sides to every story, and were I to ask their doctor his/her take on the matter, my judgment on the matter may sway.

However, more often than not, my overall impression usually does not find fault in the previous doctor; rather, I often assess mentally that the patient's disease(s) has probably evolved from their initial presentation, and had the family followed-up with their primary doctor, the correct diagnosis would have eventually been made.

I need to qualify this blog with a few thoughts:

1. Pediatrics is a different beast than adult medicine. In adults, debilitating diagnoses such as cancer, heart disease, stroke, etc. are more common, hence there is a greater propensity in adult medicine to misdiagnose a life altering ailment.

2. Doctors do make mistakes. This is not an attempt to exonerate myself or all pediatricians from errors. We are all human and every doctor has their share of war stories. Of course, we all try to keep these stories to a minimum.

3. I practice in an area of Houston where, for the most part, my surrounding colleagues are all excellent well-trained physicians, for whom I hold mutual respect. There is excellent camaraderie and perpetual educational conferences where we freely exchange information and medical trends. Thus, when a patient of their's seeks my second opinion, it is rare that I discover an egregious error.

4. Most of the mistakes I have personally witnessed are not from when patients have seen another pediatrician, rather they are seen at follow-up visits after a family has visited a non-pediatric emergency room where the physician on call did not regularly see children. The suburban strip mall after-hour clinics tend to be the most frequent offender. Of course, I have also met and know some excellent doctors in each of these settings. It just tends to be more of a crapshoot.

To fully demonstrate the point of this blog, I will delve for a moment into the minutiae of pediatric medicine. Let's take a look for a moment at the pathophysiology of bacterial pneumonia. Pneumonias can actually be categorized into 3 general groups divided by etiology (cause): bacterial, viral and atypical bacteria. Of these 3 groups, the one that can turn into an ICU nightmare is the bacterial pneumonia. The other 2 etiologies are of less clinical significance and, for the most part, are not dangerous. However, should a bacterial pneumonia not be properly treated, a normally healthy child can suffer significant consequences including the infrequent ICU hospitalization.

So how does a bacterial pneumonia evolve?

1. First, a child will catch the common cold (caused by one of many viruses). This will turn his nose into a faucet, which causes many to suffer from post-nasal drip, where the mucus runs from the back of their nose down their throat and into their lung. This essentially turns their trachea (windpipe) into a water slide, or more specifically, a mucus slide.

2. Second, the water slide of mucus/phlegm will accumulate in a pocket of their lung. Interestingly, the very cough that many parents want to alleviate and squelch, offers the best protection against the formation of these biological cesspools. In effect, cough is protective and beneficial! God is smart!!

3. A bacteria (often being harbored harmlessly in the child's nose) will ride the water slide down from the nose into the lung. Should it find an acceptable domicile of collected mucus, it will set up house and began to multiply. Once a sufficient army of bacteria are formed, the germs will infiltrate the surrounding lung tissue, firmly establishing a pneumonia.

This entire process usually takes 1-2 weeks, however should the offending agent be an aggressive bacteria, the timeline can be significantly shorter. The pathophysiology for ear infections and sinus infections is also very similar. So should a parent bring in a child during the first few days of this timeline, the appropriate diagnosis would be an upper respiratory infection (cold) caused by a virus, and thus the appropriate treatment would be tender loving care and watchful waiting.

As the child evolves from having a cold into a pneumonia, there is usually a clear change in their overall appearance. Often they will appear less energetic, have shallow labored breaths, their appetite/play will decrease, and there may be a second peak of fever. Most mothers will pick up on this and bring them back to their pediatrician for a second check. However, should the mother decide to switch doctors at this point, it may appear that the original doctor who diagnosed a cold made a mistake, when in actuality the disease has evolved since the initial presentation.

Second opinions are certainly warranted in certain situations, especially if you feel that your doctor is not adequately addressing a deteriorating illness. Either a lack of guidance and roadmapping may leave a parent feeling slightly lost and scared, or the doctor may simply be missing the boat on the underlying diagnosis.

However, it is more often the case that your child has simply progressed from their initial presentation, and allowing your own doctor to observe the change in symptoms will often be your safest recourse. Having seen how your child originally presented and then being able to see the change in presentation, will proffer your physician a bird's eye view on the entire history of the illness. Hopefully, you have enough faith in your pediatrician that you trust he has made the correct original diagnosis, and will also make a change in his assessment, should the opportunity necessitate itself. If this faith does not exist, it may be time to find a doctor in whom you can put it!

This blog is not to deter you from seeking second opinions, but rather to help you understand that sometimes a change in clinical diagnosis is not always indicative of a mistake but rather an evolution in the natural history of a disease process. And it may be in your child's best interest to stick with one doctor through thick and thin, especially if you've already found a doctor who you trust.

2 comments:

GREG said...
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GREG said...
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