The Perils of Being First

Last month I saw a woman with a few weeks’ history of pain and swelling around her left ankle. She hadn’t injured it and she had no history of gout or arthritis. It was swollen and tender but not red or warm. Moving it hurt her and she walked with a limp. I ordered an X-ray, which was negative, and some bloodwork. Her inflammatory markers were high, uric acid level was normal and antinuclear antibodies and rheumatoid factor were negative. I prescribed a nonsteroidal and referred her to orthopedics.

Almost a month later I got a call. It was the orthopedist:

“Your Mrs. Patterson – she’s got lymphedema up to her thigh. There’s nothing wrong with her ankle. I’m sending her back to you for a lymphedema workup.”

I gulped.

“She only had swelling at the ankle when I saw her a month ago, so this has changed a lot”, I said as our conversation ended.

I made sure to see Mrs. Patterson the very next day.

“That orthopedic doctor didn’t think much of your diagnostic skills”, she said. “But I told him all this other swelling happened after I saw you.”

Being the first contact in a new disease process always involves the risk of missing diagnoses and looking stupid. The last person to see a patient has all the advantages: more time for the disease to evolve and more previous tests and treatment failures to take into consideration.

Emergency room doctors, hospitalists and specialist consultants need to be honest when they disagree with the primary care physician. But they have a choice whether to assume all the diagnostic clues were there when we saw the patient or not. They also have a choice whether to be graceful or degrading if we were indeed on the wrong track when we saw the patient.

We strive for perfection, but none of us are perfect. That is the scary part about being a doctor in this litigious society. But we are in fact not held to the standard of always being right. We are only required to do what a reasonable clinician would do under the same circumstances.

No insurance company would cover a lymphedema workup for modest ankle swelling. Ordering that would have been inappropriate, wasteful and excessive.

But, as I think back on this particular case, I have once again formulated a resolution. Since I am practicing in an area where it often takes a long time for patients to get an appointment with a specialist, I need to be even clearer than I have been in telling my patients:

“If things get worse before the consultation, I absolutely need to hear about it.”

2 Responses to “The Perils of Being First”

  1. 1 Kris Deeter June 21, 2021 at 11:42 am

    Dr Duvefelt– I truly appreciate this post and the reminders behind it. I work in an ICU and often tell my docs that they have it so easy — our patients mostly come up to us with a sticker on their forehead that says their diagnosis. The good folks referring to us did the work-up and stressed about the decisions. I encourage everyone to try working on both sides!

  2. 2 John R. Dykers, Jr. MD June 21, 2021 at 4:54 pm

    The Medical Care Restoration Act makes a special point of addressing this. Compared to M4a, the Medical Care Restoration Act is smoother, more effective, Voluntary, Universal, improves quality of care, decreases cost, moves economic power, authority and responsibility, to a Dr/Pt relationship which is healing, and away from hassle bureaucracy of government, insurance or hospital interfering with healing. MCRA diminishes defensive medicine, encourages learning, preventive medicine, and patient care; restores non monetary rewards to practice of medicine and surgery, requires physicians to earn their keep, restore honor, affection and effectiveness to the healing professions. MCRA text is 10 pages 5×7 and 16 font in Chapter 2 of “The Price of Eggs Is Down”. I think you will appreciate other chapterstoo. I hope you will add your voice to permissive legislation that does not require repeal of ACA

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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