Changing the diagnosis in the face of change: against complacency


I took a good look at the hand

I kept an expression so bland

     without honest guide,

     You can run but not hide

Just keep your head out of the sand

Synopsis: I’m a family practitioner from Sioux City, Iowa.  Transitioning my career away from the brink o f burnout, I’m taking a sabbatical while my one-year non-compete clause expires.  I’m having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m in Barrow, Alaska, the northernmost point in the United States.

I took care of a patient who has given me permission to write the following information.

Hand pain, concentrated at the joints where the fingers meet the hands and the knuckles closest to those, and pain in the wrists, brought her in to see the docs here in the fall.  Concerned about some abnormal blood work, they requested a rheumatology consultation.  The rheumatologist diagnosed osteoarthritis and prescribed non-steroidal anti-inflammatory drugs (NSAIDs).  Osteoarthritis comes from wear and tear on the joints.  In the hands, it characteristically affects the knuckles closest to the nails.  It has nothing to do with rheumatoid arthritis, a disease which scourges the entire body.  Treatments for the two diseases differ vastly.  NSAIDs comprise the mainstay of osteoarthritis therapy, the powerful drugs which modulate the immune system in rheumatoid arthritis have no place in osteoarthritis.

The patient got steadily worse.  She now has severe morning stiffness, pain that wakes her up at night, and worse pain than ever in more joints than before, now including her shoulders and knees.

As soon as I walked in the room, I saw that the fingers of her right hand were swollen in a fashion that gives rise to the term “sausage fingers.”

While I’m checking for other diagnoses, I’m fairly confident she has rheumatoid arthritis.  Her x-rays, normal in December, confirm the joint erosion and bone thinning near the joint, typical of the disease.

Like every patient, she lives in a social, family, and community context.  Whatever her diagnosis, the course of her illness will touch everyone she knows in an unpredictable fashion.

My sensitivity to the rheumatologic diseases stems from my own ankylosing spondylitis, and my experience with the medical profession misdiagnosing me for seventeen years (which was the best thing they could have done for me at the time; the rudimentary treatments back then weren’t much better than the disease).

I know when I don’t know and when I don’t know I know what to do: call someone who knows more than I do.

Humans tend to complacency.  I had the urge to accept the diagnosis of osteoarthritis, because I regard the rheumatologist as having expertise in the area.  But in the end, I just couldn’t make the patient’s history and the physical findings fit.  Even if the patient had osteoarthritis in December, she doesn’t have it now.

  Patient conditions change, world conditions change, and without the ability to adapt, survival becomes problematic.

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