THE LAST WORD
Diagnosis Du Jour
When you happen upon a new diagnosis, a strange phenomenon occurs: Its prevalence increases in your practice.
Fam Pract Manag. 2006 Jul-Aug;13(7):88.
My charts have been cluttered recently with three words that have gradually crept into my vocabulary: “Eustachian tube dysfunction.” Previously, patients had “upper respiratory infection with associated ear pain” or some such diagnosis, but when a patient mentioned Eustachian tube dysfunction to me several months ago, I decided to read up on it. One of my textbooks describes it as “negative pressure” in the middle ear frequently related to upper respiratory infections and resulting in a “sense of fullness in the ear associated with mild to moderate hearing impairment.” It made perfect sense. Since then I have adopted it, almost unconsciously, as a FUD (that’s frequently used diagnosis). When patients report ear pain, I now query, “Are you sure you haven’t had a cold?” and “Would you describe it as a fullness?”
Whenever I catch myself in such a diagnostic rut, I recall the humanist psychologist Abraham Maslow, who once explained, “If the only tool you have is a hammer, you tend to see every problem as a nail.” Although Eustachian tube dysfunction may not be my only tool in diagnosing ear pain, it’s certainly one I feel comfortable with – one I understand and know how to use. And when I’m hurried or just plain stumped, it’s easy to reach into my toolbox, see my trusty diagnosis right on top and use it. “Don’t you think it could be Diagnosis X?” a little voice queries. I’ve often thought that the same concept applies to the frequently encountered but rarely studied post-CME effect: When a disease rises to the forefront of our consciousness, its prevalence suddenly soars.
It turns out that this phenomenon is more common than I ever thought. I’m seeing quite a few old folks these days with aches all over; I diagnose many of them with “polymyalgia rheumatica” or “possible polymyalgia rheumatica.” Even in patients without the classically elevated erythrocyte sedimentation rate, I often find myself suspecting an atypical case before considering whether their symptoms are related to statin use, autoimmune disease or the long list of other possible causes. For a while, whenever I would see an ankle injury, I would note that Lisfranc injury was doubtful or I would use the Thompson test to rule out Achilles tendon disruption. Then there was my methylmalonic acid phase, when I poked around looking for occult B12 deficiencies. I even had a residency colleague who loved to diagnose kids with constipation. If they didn’t have an acute abdomen, they were full of stool. In almost every case, I can link the frequently used diagnosis to a specific article, lecture or discussion that made me more conscious of and comfortable with the diagnosis.
Although I recognize frequently used diagnoses as tools of convenience, even laziness, I’m not ready to call them weaknesses. Like other habits, they simplify life. The trick is to see them for what they are and know when to put them away, go back to the toolbox and pull out exactly the right tool. I still love Eustachian tube dysfunction, and – not surprisingly – it’s a virtual epidemic in my practice. But I also try to keep the diagnostic toolbox nearby, ready for rummaging if the hammer doesn’t work.
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