Tuesday, August 25, 2015


It's easy to assume that a patient with a poor social situation who repeatedly shows up to the emergency room with an exacerbation of chronic medical conditions is having trouble adhering to home medications, or that a patient known to have a history of opioid abuse presenting with a frequent complaint of pain may just be seeking narcotics instead of having an actual organic process causing the pain.

Most of the time, making that quick assumption saves an unnecessary admission and helps to reduce the strain on the health care system. However, there are times that making that assumption could potentially put certain patients at risk, and it is important to make sure to take a step back and look at everything prior to making a medical decision.

I was reminded of this one day during residency with regards to a particular patient who had a history of opioid dependence. She came to the hospital complaining mainly of abdominal pain that she said was unrelenting; nothing could make it better except for pain medications, she told us. Initial labs looked relatively unremarkable, but since she still was having abdominal pain, we made the decision to admit mainly for pain control.

During her hospitalization, she was getting pain medications, and every time we saw her in the morning, she was complaining about the pain not being well controlled with the current medications. The thing that complicated matters was that every time I would walk by her room, she would be sleeping comfortably in bed, or sitting up eating food without any issues. When I went in to ask her what was going on, she would start talking about her pain again and asking me for an adjustment to the pain medications she was receiving.

At this point, it was easy for me to start assuming that she was just taking up a hospital bed in order to receive pain medications. After all, she did have a history of opioid dependence, so what else could it be?

My team was at a loss; we could not send her out with her pain being uncontrolled, but nothing on physical exam or labs stuck out as a potential cause for her pain. Finally, as a last resort, we decided to get an ultrasound of her abdomen and pelvis to evaluate what was going on since we had no other explanations. Our thought was that if the imaging came back negative, we would have enough evidence to say to her that there was no organic cause for the pain, and that she could ultimately be discharged home with outpatient follow-up.

To our surprise, the ultrasound came back positive for a large ovarian cyst that was beginning to cause ovarian torsion. It was an unexpected finding given the intermittent pain that she had. We thought there would be an elevated white count or another lab finding that would indicate something was going on in the abdomen or pelvis, but nothing helpful came back on her labs.
The next thing I knew, she was being transferred over to the obstetrics and gynecology service, and she ultimately needed a surgical procedure later on during the admission. All I could think to myself was that if we had waited longer to do imaging, just because we assumed all this was in line with her opioid use, a more serious situation would have come up.

I and the rest of my team fell into the trap of treating our idea of the patient, instead of the patient herself. We treated her in a way assuming that all this was based on opioid dependence, and it was only near the end that we started to think that maybe this was something else. And to be honest, after having prior experiences where people with chronic opioid dependence have fooled me and other physicians in the past and have ended up receiving free narcotics for no known cause of their pain, it is not surprising for us to make this assumption in the setting of seeing numerous patients in a day and trying to efficiently make a diagnosis.

Most of the time, this is a reasonable assumption to make, but sometimes we have to remind ourselves to keep an open mind in terms of what else could be going on with the patients we come across.

We have a tendency to put people in a box, to immediately form assumptions of people based on what they look like or what we know of them from previous interactions. This extends into medicine, where we go through numerous medical charts to figure out what may be going on with the patients that come across our paths. Integrating past history with the current presentation, we come up with an idea.

We think we know what is going on with a patient, and based on that, we figure out a treatment plan that we may become more connected to depending on how well the data correlate with each other. It is easier to have an idea match up with the reality of the patient in front of us when it comes to a purely medical history, based on prior labs, vital signs and imaging.

It is a lot harder when what we are going on is a social history. Perhaps the patient is a homeless person who has not seen a doctor in many years. Perhaps the patient has a known history of substance abuse with prior admissions for substance withdrawal or dependence. Most of the time, the assumptions we make based on a particular social aspect of a patient match up with what is actually going on, whether it be medication non-compliance or seeking of narcotics.

However, this prior event taught me, and should continue to teach all of us as physicians, that an idea that is easy to become married to in the setting of medical care may not be the reality. That time, the idea we had about the patient was wrong, even though numerous things about her presentation pointed to that idea. An organic event leading to her presentation was actually happening, despite the lack of significant prior medical history we had.

Thankfully, we changed our assumptions before anything got worse, but there are probably examples out there of the clinical situation getting worse prior to physicians changing their assumptions. Any doctor, no matter where they are in their training or practice, is vulnerable to ultimately treating ideas of patients rather than the  than the patients themselves.

We should always take a step back and look at the whole picture to make sure we have the right idea of patients so that we end up correctly treating them. At the end of the day, it is the patients, and not our ideas of them, that depend on the medical decisions we make.

Courtesy of:  http://www.medpagetoday.com/InfectiousDisease/Ebola/53217?isalert=1&uun=g906366d4471R5793688u&xid=NL_breakingnews_2015-08-25

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