Leana Wen, M.D., joins the conversation to discuss her 8 pillars to a better diagnosis.
Have you ever walked into a doctor’s office, waited for your turn, spoke to the doctor about your problem and then walked out as confused and unsatisfied as ever? Well you are not only. Joining the conversation today is Leana Wen, M.D., who says that doctors are moving away from thoughtful engagements with patients to reducing them to just a list of symptoms. Wen is teaching patients that they need to advocate for their own health by asking for a diagnosis.
Leana Wen, M.D., is an Emergency Physician at Brigham & Women’s & Massachusetts General, & a Clinical Fellow at Harvard Medical School as well as Co-Author of the new book, When Doctor’s Don’t Listen: How to Avoid Misdiagnosis and Unnecessary Tests.
Be sure to tune in for the full conversation at 3:30 p.m. today and check out an excerpt from her book below including her 8 pillars to a better diagnosis.
“The College Student with a Bad Headache”
The next story comes from a major teaching hospital in Boston. Recall that there are both resident physicians and attending physicians (along with nurses, techs, and so forth) who provide clinical care in teaching hospitals. This example of cookbook medicine illustrates how differences of opinion can play out among practitioners.
Meet Danielle La Conte is a twenty- year- old college student at the New England Conservatory.
Today, Danielle comes to the ER with a headache. When she woke up this morning, her head hurt badly. Her mouth was dry, and when she tried to get up to go to the bathroom, she felt like she was getting faint.
She attributed all of this to drinking too much the night before— normally she has one or two drinks when she’s out with friends; last night, it was one of her roommate’s birthday, and she did three or four shots and had a few beers on top of that.
“The last time I had a hangover was a couple of years ago, and I think this was how I felt then,” she says. “My roommate Jackie told me to drink lots of water.”
Throughout the day, she felt too nauseous to eat or drink. When the headache didn’t go away in the afternoon, she called her mother. Her mom convinced her to go to the ER to make sure everything was OK.
Triage nurse: I see this young girl who tells me that she’s having a bad headache after drinking last night. She doesn’t have a fever. The only thing abnormal about her vital signs is that when she stands up, her heart rate speeds up. That’s a sign of dehydration. She says her headache is a 10= out of 10, but I see her there in the waiting room, chatting away on her cell phone with a magazine open on her lap, so how bad can her headache be, right? I figure she needs to get some treatment for her headache, probably some fluids for her dehydration and some Tylenol, so I send her to the Fast Track area. That’s the same area we put coughs and colds and minor injuries, because the treatment is simple and then patients are on their way.
Nurse in Fast Track: I see that the triage nurse had written “10/10 headache.” I ask her more about her headaches, and she tells me she’s had headaches before, but this is different. She doesn’t say why or how, but it’s just different. And she says that this morning, she just woke up with a pounding headache and then threw up.
Danielle: Yeah, I tried to eat and then I threw up. I think it happened to me last time when I drank too much. That’s what my other roommate Mary Ellen says happens the morning after when you have a hangover, too. I didn’t think it was that big of a deal. But then all these doctors start coming in and getting me scared.
Attending: The nurse approaches me and my resident and tells us we should come see this patient. She describes a young girl who woke up and developed a headache— worse than she ever had in her life— with a fairly sudden onset. And has been vomiting. As far as I’m concerned, that’s a classic story for a subarachnoid hemorrhage— a rare, but very serious type of bleeding into the brain.
Resident: I go to see Danielle. As I talk with her, I begin to feel more reassured. Danielle says to me that she has had headaches before, that this is a little different but not that different, and that she’d been partying pretty heavily last night. She tells me that she woke up with the headache, vomited twice, and hasn’t felt like eating or drinking anything all day. It’s been a few years since I was in college, but I haven’t forgotten what a hangover feels like. I attribute the nausea and vomiting to her hangover, and the headache, at least in part, to dehydration, so I order her symptomatic treatment: IV fluids, Tylenol, and medication for nausea. I don’t think it’s likely that this is a stroke or bleeding in the brain because her story is so consistent with a hangover.
Attending: Attendings have to see every patient who comes through the ER, and ultimately we are the ones responsible for the medical decision-making. In this case, I disagree with the resident. A subarachnoid hemorrhage is no joke. It’s a life- threatening diagnosis. One of the hallmarks is “worst headache of your life,” which the patient does not deny when I ask her directly. She rates her pain 10 on a scale of 10. That’s pretty high. The pain scale is a subjective method for measuring pain, and she’s talking to me normally, not like she really has the worst headache of her life (and we’d seen her text on her phone)— but still, it’s documented that her headache is 10 out of 10. Since brain bleed is a “can’t miss” diagnosis for doctors, we have to “rule it out.”
Danielle: I get a needle in my arm and they give me some fluids and some medications for nausea that really help. After half an hour or so, my nausea’s completely gone and my headache’s down to about a 3 out of 10. Like I wouldn’t even have noticed it if someone didn’t ask me about it. But they tell me I might have bleeding in my brain. I can’t believe it. How did that happen? I think I was drunk last night but not that drunk. I didn’t fall or anything. I’ve always imagined that people with a brain hemorrhage would be really sick— unconscious or in a coma. That’s pretty scary stuff ! They tell me they need a CT scan of my head, so of course I said yes.
Resident: The head CT scan is negative. You would think this is good news, and yes, it is, but have we really “ruled out” a subarachnoid hemorrhage? Head CTs can miss up to 5 percent of all subarachnoid hemorrhages,1 so the textbooks say that if you suspect a bleed and the CT is negative, you have to do another test: a spinal tap.
The question I have is this: do we really suspect bleeding in the brain? And if it’s not a bleed, what else, if anything, do we need to be worried about? By now, Danielle is feeling much better. She’s on the phone with her friends making dinner plans. She asks me if she can go because she has a music rehearsal session in an hour, and she wants to shower and change before that so she can go out to night. Admittedly, I haven’t seen more than a couple dozen patients with a true subarachnoid hemorrhage, but this really doesn’t fit the picture of someone who is having a serious bleeding in the brain.
Nurse: The whole thing is getting ridiculous. Yeah, I was worried when I first heard the story. But then it changed. I talked with her two roommates over the phone and they confirmed her story, that the onset of the headaches was not sudden and this same thing happened when she got really drunk a few years ago. Now, it seems clear that the girl has a hangover. If I had a hangover, I wouldn’t want a head CT or, God forbid, a spinal tap.
I tell all my girlfriends, stay out of the ER if you have a hangover, ’cause I know what they would want to do. The docs, they always want to “rule out” this or “rule out” that because they’re so worried about getting sued.
Attending: Do I really suspect that the patient is having a bleeding in the brain? No, I don’t. It was very unlikely to begin with and I think it’s even more unlikely after the head CT came back negative. But making sure it’s not a head bleed is the standard of care. If we want to rule out a subarachnoid hemorrhage, we get a head CT; if that’s negative, then a lumbar puncture. That’s the pathway we follow.
You’ll get burned if you don’t follow this pathway. A couple of years back, I had a case where I missed a subarachnoid on a young woman— the resident and I didn’t think she could have had it, so we sent her home without any studies. She came back the next day in a coma. In looking back, the problem was that we should have taken a better history— it would have been pretty clear what the problem was because all the warning signs were there. But I just can’t afford to miss this kind of diagnosis again.
In this case, I can see that the resident isn’t as keen to follow this pathway, so I tell her that if she doesn’t want to talk to the patient about the spinal tap, I’ll do it.
Resident: When my attending put it like that, it was hard to argue. His point is that this is the subarachnoid algorithm we’re following, so if we get one test, we need to do the other part of it, too. What I don’t understand is how our patient is on the “subarachnoid pathway” if it’s not the most likely diagnosis by a long shot. Also, is it true that once we’re on the pathway, there’s no way to get off ? It seems bizarre that if we do one test, we are obligated to do another. I actually want to send her home. Nevertheless, the attending has the final say, so I follow his lead and tell the patient why we need to do this lumbar puncture.
Danielle: A spinal tap? When they first tell me, I think it’s a bad joke. I’ve never heard of anyone who got a spinal tap. It sounds really painful. The resident tells me one of the common side effects is that some people experience a worse headache after the procedure. So what’s the point of that when I’ve gotten rid of my headache? I really don’t want to do it.
Actually, my friends are already on the way to pick me up for rehearsal because I thought I would get to go. I get dressed. Then the older doctor comes in and says if I don’t get the spinal tap, I’ll have to sign something saying I’m leaving against medical advice and my insurance may not pay for this ER visit. I can’t believe it! At this point, my roommate Mary Ellen is there, too, and she swears up and down that we had a lot to drink last night and that my headache this morning wasn’t that bad. I phone my mother to talk to her, then the doctor asks to speak with her. He gets on the phone with her and tells her I need it. My mom freaks out and says she’s driving from Cincinnati to see me. I feel like my hands are tied.
Nurse: They all get ready to do the lumbar puncture and have the gowns and needles and everything open. The resident is in there getting the needles and tubes ready. Danielle says she has to go to the bathroom. She goes out, and never comes back. She leaves all her clothes and shoes, and runs out in her hospital gown! I think she knew best, to just get the heck outta there when she had a chance.
From When Doctors Don’t Listen by Leana Wen, M.D. and Joshua Kosowsky, M.D. Copyright © 2013 by the authors and reprinted by permission of Thomas Dunne Books, an imprint of St. Martin’s Press, LLC.