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Emergentology

What ‘Diagnosis’ Got Right

Walker, Graham MD

doi: 10.1097/01.EEM.0000616472.22734.4b
Emergentology

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I ranted last month about how disappointed I was with Netflix's medical mystery reality show “Diagnosis” featuring The New York Times' Lisa Sanders, MD. The first episode is unrealistic, and felt like an unfair portrayal of the medical system. Fortunately, the next six episodes give a human and touching look at patients and their families and the stress of living with an undiagnosed illness in oneself or a loved one. Even after the diagnosis is made, families are still challenged by the now-named disease.

The remaining “Diagnosis” episodes touch on several issues relating to disease, illness, and our health care system that will be all too familiar to emergency physicians:

  • Medical debt and not being able to “afford” being sick
  • The burden that adults with illness face when trying to support their families and hold a job without (or even with) sick leave
  • The depression, anxiety, and emotional exhaustion from illness
  • Any number of physical, emotional, and mental stressors that loved ones and caregivers face
  • The fear of not knowing
  • The anguish of wanting desperately to help a loved one
  • The anger and frustration when medicine cannot come up with an answer or has multiple different answers and opinions
  • The distrust of the medical system when diagnoses and treatments are not helping

Each of these gave me pause and really helped me empathize with patients who have any disease burden. “Diagnosis” gave me a peek into these patients' lives, the coping strategies they use to make it through the day, and the numerous challenges they face on a daily basis, outside of me assessing them in a limited, controlled environment like the ED. These episodes made me realize what a low bar we have set for discharging medically challenging patients from the ED: Can you walk? Can you eat, drink, and swallow? Certainly, the world outside the ED is much more complicated than walking and swallowing, but navigating stairs or a toilet or doing the dishes may be monumental tasks for some.

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Objective Abnormality

The four most important pearls from “Diagnosis” for me are hopefully picked up by patients:

  • In almost all of these cases, some sort of objective abnormality is found.
  • Several cases conclude that a patient's very real symptoms are likely tied to the mind, that the patients are not crazy, and in one case, a patient's symptoms improve with psychotherapy.
  • Medicine is really difficult and mostly full of really hard-working people who are humans, not magicians.
  • There are real consequences to invasive testing and treatment, which is one of the many reasons most doctors are hesitant to start just trying stuff.

First, and this is obviously not a perfect rule, but most of the mystery cases featured in “Diagnosis” have an objective abnormality: brain masses, elevated CPK levels, sinus arrests. And many of the diseases discussed and ruled out before each episode are crossed off the list based on objective testing like labs or imaging studies. Obviously, I think this pearl must be taken with caution when applied to emergency physicians because we have a fairly limited number of tests at our disposal. And the pearl isn't perfect, even in emergency medicine—we've all seen the urban-legend appy patient with a normal WBC count and CT scan. That said, most of the time, even with extremely rare diseases, something objectively wrong can be found.

Second is the stigma that even very ill and burdened patients have against functional diagnoses. A young teenager with chronic vomiting, sick enough to have a port-a-cath placed in her chest wall and bedbound for six weeks after a blood patch, refuses to accept that her illness may be functional in origin even when she and her family talk with a patient who has a similar issue that was cured at a specialized center.

Third is that many smart, experienced, wise physicians may disagree with each other about a medical opinion. When someone has rare, infrequent, or uncommon symptoms, lots of people have diagnoses, and everyone has a different perspective. That's clearly frustrating for patients, but physicians are just humans with experience and training, and patient symptoms might not perfectly fit one disease or another.

Finally, the show gives several examples of patients trying therapies unsuccessfully and facing consequences from them: symptoms getting worse, prolonged hospitalizations, and complications from testing. Less is usually more, but when someone has unexplained, serious symptoms, they're also more willing to undergo additional testing (and are more susceptible to snake oil salesmen).

“Diagnosis” is a great look at what it's like to have any chronic illness, mysterious or not. Skip the first episode and appreciate the look inside patients' lives at home, away from the hospital.

Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns athttp://bit.ly/EMN-Emergentology.

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