To the Editor:
I greatly appreciate Drs. Norris and McGowan's correspondence and I share their many concerns. I certainly agree that, as physicians, we should be monitoring constantly those patients with diagnoses of exclusion or we may easily miss the true cause of illness. As providers, I'm sure that we all have seen a similar case of misdiagnosis. Whether it be an autoimmune disease masquerading as a fibromyalgia or pericarditis masquerading as costochondritis, we should never place our complete faith behind a single diagnosis.
The law of clinical inertia often amplifies a diagnostic label. In a busy clinic, the path of least resistance is often the path involving the previous diagnosis as opposed to creating a “fresh look.” Neither the provider nor the patient (nor the insurance company) look forward to a brand new work-up with every visit. As such, Newton's corrupted second law seems to reign supreme, unless providers make that herculean effort.
Do I have the energy and patience to revisit a differential with every patient I see? No. But sometimes we all have to break the laws of physics. I challenge all providers to look at their difficult patients with diagnoses of desperation (especially when their treatments just are not working) to take that second look, revisit the work-up, and see if that diagnosis of exclusion has just excluded the diagnosis.