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  • Fred Bagares

"I know what I have." The pitfalls of assumptions while in pain.


When I see patients, I have them fill out a pain diagram to help localize their pain. One day, a patient came in and did not fill out the diagram but wrote down the words: adductors, piriformis, gemelli.

These are muscles in the butt and groin region that can cause pain. However, these same areas have tons of pain generators and that's assuming there is only "one thing going on."


However, this triggered a series of questions in my head:


Was she right?

How did she come to this conclusion?

What do I say if she’s wrong?

Does anybody have to be “right” as long as they get better?


As humans, we all come in with biases through our experiences.  I view a “diagnosis” more as a construct of what I think is happening versus what is actually happening.  Plus it can be used to communicate to other providers what we believe is the problem.  While helpful at times, they can also also limit us providers and patients.  As a student, I diligently gathered ALL the information to understand the patient’s history and their entire medical workup.  At some point I started to realize that I was putting together a puzzle that others (healthcare providers) wanted to see.  Perhaps there were missing pieces to this puzzle?


I personally make it a point to not read any imaging studies and/or notes before seeing patients just for that very reason.  I like to come to my own conclusions with as little bias as possible.  However, sometimes the challenge is when I come to a conclusion that differs from what the patient thinks is the issue.  Arriving at a different diagnosis can often be received a lot of ways from patients ranging from feelings affirmation to being offended.


Deconstructing or “unlearning” someone’s belief system/framework is sometimes necessary in the rehabilitation process. It’s especially hard to do in the 15-30″ appointment world we live in. It can be hard to connect with a patient if what they are looking for is affirmation of their beliefs. Imagine getting an MRI for a knee problem where the radiologist says you have a "meniscal tear." Your primary care doc counsels you and talks to you about non-surgical and surgical management. You get referred to see an orthopedic surgeon but it takes weeks. In that time you do your due diligence (aka Dr. Google haha) reading all of the success and horror stories. By the time you see the orthopedic surgeon you are good to hear all the options, risks, post-operative care, etc. The orthopedic surgeon takes a look at the images themselves and says, "Yeah, you don't have a meniscus tear. I think the radiologist may have over read the MRI. I actually think that this is a patellar tendon problem." This happens ALL. THE. TIME. Who's to say the radiologists is wrong or the orthopedic surgeon is right? My point is that it's hard to keep an open mind when you come in with pre-conceived notions of the problem.


Getting back to my patient…was she wrong?  No, but I did explain that I think that her symptoms are a little more complex in nature. At the end of the day having her see things my way was not necessary for her to get better. From my standpoint, being "correct" is not as important as long as the treatment plan taken. She wanted to do the work to get better regardless of the” diagnosis” so I thought it would be best to leave it alone.


Thoughts?

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