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Sunday, March 8, 2020

Nothing Seems to be Too Wrong Syndrome

 "Nothing Seems to Be Wrong" Syndrome: Confusion created right at the start of treatment.


Many patients come to my office with a difficult problem and a pattern of treatment I would consider sub-par. This sub-par treatment may be performed by top physicians, physical therapists, and others in the health care system, all with good intentions. I am amazed so many times at the previous treatment given, and I think that the providers must have been burnt out when treating the patient. Why were these good clinicians giving patients such inadequate treatment? It took me a while to see a pattern in these patients. I call this syndrome of inadequate care "The Nothing Seems to be Too Wrong" Syndrome (although I still grasp for a better title).
Yesterday I saw Helen for the first time. Helen matches the profile of this syndrome well, and I even told her so. She has had a significant ankle problem for several years, and very inadequate treatment. The injury to her ankle is very disabling, she can not run or jump due to the injury, and she is only 21 years old!! Helen is cheerful, very positive in nature, bubbling in personality, walked into the office without limping, and looking vibrant and healthy by any definition. After examining her ankle, even though it was obvious she needed X-rays and an MRI, I had to force the words that she needed these tests out of my mouth. There is a psychological block to have the patient spend the money, time, effort, etc. to order these tests, since the patient outwardly seems to have nothing wrong (no bone is sticking out the side of the ankle). 
Yes, the patient is too healthy-looking with a persona beaming to have a serious injury. Does that make sense? No!! Anyone can get a serious injury. No health care provider actually wants anyone to have a bad injury, and the reasons at any one moment can be numerous. A bad injury denotes possible diagnostic dilemmas, possible difficulties in treatment reflecting poorly on the provider, possible requirements of effort that a burnt-out doctor, therapist, etc. may not want to expend . . . the list goes on. But, for the average clinician, a serious injury to an otherwise vibrant healthy-looking patient is just too sad on a human level, and so easily dismissed. The hope then shifts to a desire that the patient has something that they will recover from with ease. Should health care providers be allowed to be human in the twenty-first century? I hope so.
What are the components that affect this syndrome? First of all, it is the physical nature of the patient. Secondly, and probably the most important, it is the positive personality of the patient. This positive personality, when the health care provider is collecting initial impressions, may steer the course of treatment away from a potentially negative diagnosis. How is a negative diagnosis avoided? One way is that the proper tests to make that diagnosis are never done. If done, the results of the tests may be minimized. If you match the positive personality of the patient (glass is half-full) with an otherwise positive (glass is half-full) doctor, trouble brews in setting the course correctly in developing a great treatment plan.
What does all this really mean? Patients who feel they may have a serious injury need to push these health care providers along gently (they are not machines). Assume that they are human and actually don’t want to learn any bad news about you. You, on the other hand, want your body to work correctly for many years to come and need their help to make things right again. How are things made right again? First step is always in ordering the right tests, and then moving the treatment through the roadblocks, and over the plateaus. 
Part of this syndrome is then matching the implied need of the patient to the implied need sensed by the doctor of the problem. Trouble happens when the patient and doctor can not agree on the present need of treatment. 
I have found as my long term patients have morphed into friends over the decades, I am very prone to this problem. I am glad I have partners to refer to for second opinions. I see my patients back regularly to check on their progress. I try to push through the psychological road block I put up myself for really not wanting this to be a bad problem. I recognize this in myself. Plus, I love the KISS principle (Keep It Simple Stupid). I must always ask if I am under treating for the patient, for me, or am I appropriately treating the problem. The Art of Medicine can be complex, and just take some extra thought. 

The following was an excerpt from my book "Secrets to Keep Moving: A Guide from a Podiatrist."

2 comments:

  1. Dr. Blake, this is so true in the medical field. I often tell persons with whom I'm working with who I know are in great pain, both physically and mentally, to let the doctor know what they are feeling and going through. I do tell them to keep it to symptoms; what are they, what makes it better, what makes it worse, the drill we all know. But like you so shared, many persons, especially women are passed by or shall I say, "not" believed. Thank you for sharing this. I hope those of you who need answers to general questions will send them. Carol in California, patient of Dr. Blake since 1999.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.