When the Disease Eludes Diagnosis
By BARRON H. LERNER, M.D. Lucy, one of my longtime patients, has a neurological ailment she believes I have been unable to adequately diagnose. Although I hope to make further progress on her case, I have also told her that there may never be a definitive answer. Not surprisingly, she is feeling pretty frustrated with me. Why do doctors and patients often approach the diagnosis of disease so differently? Part of the answer lies in the concept of triage — the notion, originated in wartime, of caring for the sickest and most salvageable patients first. Once they were saved, attention could be turned to less drastic cases. A similar strategy has evolved in emergency rooms, where physicians are trained to “rule in” or “rule out” severe conditions. Thus, doctors immediately consider heart attacks or pulmonary embolisms for patients with chest pain, and intestinal rupture for those with abdominal pain. But what happens when these conditions are ruled out? In such cases, doctors proceed to se...