Wednesday, March 5, 2008

Waste basket diagnosis

When I was in my sportsmedicine fellowship, I used to see a small collection of patients come into the office as a referal complaning about shoulder and neck pain. Many times it would have been fully worked up by the primary care doc and with minimal signs (if anything) on xray and mri. The usual diagnosis would be that of an issue or problem with the joint involved most. Many times it would be shoulder bursitis or pinched nerve of the neck. We would again get them into therapy, thinking the therapist used by primary care was doing something wrong. Sometimes an attempt at different medicines, often stronger, and maybe a steroid injection would be attempted. After another exhausting work up to look for neck or shoulder pathology (without finding anything) and yet a patient that is still suffering, a diagnosis of a mental disorder or a malingering patient just trying to get money from the car accident or the government was made. The average age of onset is usually 20's but patients are into 30-40 with chronic pain.

Symptoms were usually the same: poor sleep, fatigue, multiple trigger points to muscles (mostly back), depression and headache. There is usually a trigger event like an accident, infection or stressful time of life. I found a diagnosis of fibromyocytis, also known as fibromyalgia being kicked around that lumped all these patients together. So actually other doctors were getting the same kind of patients and wondering if there was a syndrome that was being missed. Somehow though, it was thought of as a waste basket diagnosis since it wasn't "real" and was just coined so doctors could identify that a patient was suffering from something. Western medicine couldnt do anything with it short of sending the patient to a psychiatrist for psych meds. Being in sportsmedicine, I would utilize very gifted physical therapists that would have an eye for finding movement disorders and they would usually be able to help a patient get mobility back and work on flexibility. This alone would make many people feel better than they every had thus less medicines and eventually less side effects from medicines. Usually when a patient began to believe in themselves again, outlook would be better and they would be more involved with what works and get healthier. At one point, I had alot of patients with this diagnosis coming to me. I have to admit, I did get burned out since the diagnosis comes with many complicated issues and sorting things out took alot of emotion out of me. It was always rewarding to get the patient pointed in the right direction and see them get off medicines but if this took 45-60 minutes to evaluate and a family practice doctor that works for a hospital is expected to see a patient every 10-15 minutes.....I would get very backed up for the day. "Dr Saguil is running behind" was a common statement in my office (but patients were willing to wait! and I wasnt sure why they waited so long! I guess it was because I was listening and giving them some useful guidance.)

In a few years the American College of Rhuematology backed up the fibromyalgia diagnosis by saying that if someone came in with no other medical problems (like hidden hepatitis or arthritis) if they had sleep disorder, depression and 11 of 18 painful areas of muscle to specific areas on the body, the diagnosis was true. This was a "touchdown" for people with FibroMyalgiaSyndrome since a big authority said it is true and can be treated. Guess how it was treated, medicine for sleep, medicine for depression and physical therapy! So now the rhuematologists were getting all the referals instead of the orthopedic surgeons and they were doing the same thing.

Fast forward to the millenium, big difference now is the sprouting up of pain clinics! FMS is still being diagnosed but since its a very well documented disease, any average doc is treating it with a medicine for sleep, a medicine for depression and immediate prescription writing to see a therapist.....oh and a muscle relaxer and narcotic. Note....narcotic! Patients are being treated more readily by the unexperienced doc, usually adequate at first but with the next flare up, (and it is a lifetime diagnosis so a flare up is going to happen 1-3 times a year- especially in chicago), the frustrated doc is going to give potent medicine to quiet things down, but depending on the intensity of the flare, and other issues at the time, a narcotic will be relied on probably a little to much. Then comes the fast food mentality. Patient not educated on how important it is to get the fire put out immediately before resuming work and/or child care so reliance on meds like muscle relaxers and vicodin becomes more of the daily medicine than the "only for emergency" medicine. Then when the patient calls for a refill....referal to the pain clinic for narcotic management.

Don't get me wrong, the pain clinics are good, they did have a great headstart but they are now being dumped on by every doc that doesn't have the time to care for the 20-40 year old women (and rarely- men) with FMS. There are waiting times of up to 2 months before a patient can be seen. If you have ever suffered from a trapezius that is numb, tingling and a trigger for headaches and nausea, you would understand that just taking a muscle relaxer and popping a narcotic to get to that Jimmy Hendrix level of being high doesnt cut the pain and dysfunction. I have experienced this and it came after the emotional separation of me from my practice in 2005 when my previous hospital said they wanted to cut my pay since I wasnt producing like the docs in the rest of the country.

Suffice it to say, while in florida, I was finding the same suffering from FMS and because there werent as many "creative" docs there, I had no competition for patients but there was also great acceptance by patients for alternative medicine docs. The patients were getting smart and going to other forms of healing and getting better. Acupuncture works (no matter what a standard questionnaire says), mind body strengthening helps, movement like tai chi or the more popular yoga is a must and nutrition education is mandatory. You can always go the the pain clinic, get hard medicines for a few months, maybe a steroid triggerpoint injection her and there while you are on your way to flexiblity and healthy living.....or....just start with the movement, nutrition, time off and skip the narcotics.

Lets see where patients get dumped in the next decade.....with the government approving some alternative medicine therapies, may not have to get dumped anywhere since education is being given by those who dont have as many time constraints on visit time and those same....only can rely on movement since aggressive medicines are only given by doctors. I do believe there is a place for everything but not in excess and again I maintain it always starts with a good history and physical.