Why Are There So Many Wrong Diagnosis?

He was a pleasant young man. A bit angry, but I could understand that. His skin was dark and as much as it hurts me to admit, that can still, even in the 21st century, be a factor in how one is treated in some schools or jobs. So when he complained about that, I could not disagree. I really liked him and still do. He had been on a brand new, expensive and hard-to-get (in the public mental health system) anti psychotic for the last several years. He was struggling at school, and wanted to study more for a good job in the business world.

"It doesn't work anymore," he said. "I have voices and they tell me horrible things. I know I can resist them and I am safe and all that, but I want them to go away and this medicine does not make them go away. I don't think it ever worked as good as the old stuff." I asked him why on earth anybody had ever taken him off the old stuff that worked.

"They thought I was allergic, but they were wrong. I should be on the old stuff."

I asked him, quite simply, how he knew they were wrong. "They said my rash was an allergy to the medicine. But I have not had any of that medication for a lot of years, and I still have the same rash."

Hmmm...

He was really surprised when I got out of his chair, walked around the desk, and took a look at his rash.

His "rash" was two lateral places on his scalp, which looked as if he had shaved it only a couple of days before. He had never had any rash on his body or arms or anything else, he claimed, but the "rash" I saw. I looked at and asked about the usual things I would have expected to see in a drug rash. He not only did not have them in the present, but he swore up and down he had never had them.

Not only was this NOT a drug rash, but I knew what it was - a seborrheic dermatitis. I had seen it years ago, during medical school in of those little ochre-colored brick pre-World War II hospital buildings in Amiens, France. Big letters on the front of the building spelled "Dermatologie." Later, the building would be demolished and a new and modern hospital erected. The dermatologist was a dedicated man, who did rounds himself on Sundays to oversee fatigued older women who sat with their legs covered with giant diabetic ulcers in enormous vats of fluid of some special recipe. I remember trying to help them appreciate the joy of wiggling their toes.

I remember in outpatient clinic, seeing a young student from Nigeria, who had consulted for similar lesions in his beard. I recognized the lesions. That is where I had seen, for my first and last time, seborrheic dermatitis in a gentleman of color.

But I've never really been a dermatologist, and life has been too busy to keep up with dermatological therapeutics. Aside from telling this southern California patient to keep things clean, I could not do much for the rash. But I could give him his old medicine back.

I told the young man that he could see a dermatologist through his primary care physician. He probably won't, as he hates all doctors (he only puts up with me because I am part of his system) and I do not expect him to seek treatment for a painless lesion on his scalp which he cannot see except in a mirror and which he has had for a few years.

What really bothers me is that if the other doctors had been correct and he had been allergic to his "old" medicine, then giving it to him again could have been the cause of a potentially deadly anaphylactic shock. If someone has told you that you have had an allergic reaction to a medication, then if they are correct, you should never, ever, take it again. There are scary stickers all over medical records to this effect.

I had to be very sure of myself to give him a prescription for the old medicine, but I did. I got him to sign a consent form and even told him if I was wrong, then there was a potentially life threatening risk. He told me I was not wrong, and he had faith in me, and signed the paper.

I talked to his social worker later, after the medication change. She told me the patient was doing the best he had done since she had known him, clear headed, doing well in school and making career plans.

To say I had been gratified put it mildly. I do not like to take risks with patients. I had worried, wanted to check on how he was doing on his "old" medicine. I had warned him carefully of any and all allergic signs to tell me. There were none.

I believe I changed his life around and this joy gets me through many frustrations. The question is, how could I do this?

1. My French medical education was, and still is, second to none. The Nigerian student who had been having trouble with his beard in Amiens, France would have been very happy indeed if he had known his problems would help a brother in southern California whom he would never meet and probably would have liked a lot.

2. Doctors are frightened, often poorly educated outside their own specialties, hesitant to seek consultation, and often take extreme measures to "cover their asses" when decision is required. Maybe doctors don't "remember" things they have not seen since medical school. I remember generating a heightened focus and residency for my early clinical work, or "les stages" as they called them in France. I knew I had to remember everything I saw because someday it could be somebody's life and limb in the balance.

Anybody who knows anything about drug rashes should have been able to see these scalp lesions were not one. If they could not see, they could ask a dermatologist. Inconvenient, takes a long time to get a consult, but a collegial "curbside" consultation might, if the psychiatrist had the right vocabulary to describe the lesion to a colleague dermatologist, even have resolved this one over the phone.

Like psychiatrists, doctors in other specialties probably tend not to question that which has been said and done before them.

3. Most doctors tend not to listen to patients, I'm sorry to say. It is not easy to take the word of a patient over the word of other doctors. It includes putting yourself out on a limb in a medical record, which could be read back aloud to a jury by a prosecutor if something went wrong and you ended up in court. I will admit I went the extra mile in documenting my decision in this case.

I have known several doctors who have a chronic distrust of patients, just like the fictional "House, MD" on television. I do not think they are happy people. Now patients do lie sometimes. But they need motivation to lie, like the proverbial "secondary gain." Patients sometimes lie, for example, to get a pension or to keep it going.

This patient had no reason to lie, nothing to gain at all. Besides, there are some fairly good ways of "reading" people to see if they are lying or not. Nothing known to me is 100% accurate, despite the alleged science on television programs like "Lie To Me," a marvelous series which I enjoy. (To their credit, they have included things that falsify their science, like apparent partial facial immobility from Botox.)

If anyone has a motivation to lie a bit, it is the doctors who lie a bit in the "cover your ass" direction. Although Dr. House in his series seems to get only patients for his staff in training that lie at least once per hour episode, this is emphatically not the case in real life. I need to relax and to be really cheery and to work hard to relax folks, but I do not believe that my patients generally lie. I work on the assumption that they speak at least mostly truth, and I think I am usually right.