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Her Various Symptoms Seemed Unrelated, Then One Doctor Put It All Together

nytimes.com

61–70 of 118 posts

Re: Her Various Symptoms Seemed Unrelated, Then One Doctor Put It All Together

#62
post #13

> Huls hadn’t heard of Schnitzler syndrome, either. He came upon it by using the database PubMed to look for a disease that matched the patient’s symptoms. He made a list of her symptoms and abnormalities. To get the full picture, he combed through her earlier electronic medical records, now archived in an old electronic warehouse, and found that her symptoms had started maybe a decade earlier. Then he looked for a d…

My first reaction to these things is that there should be a large database of diseases and symptoms along with some statistics about how strong the correlation is between the disease and symptoms. I don't mean "database" like pubmed. I mean something more machine readable with consistent coding so a symptom might be "elevated IgM" in english. The trick is coding something like that with consistent names for the teste…

It’s hard to convince institutions to release data locked up in EHRs (eg EPIC) due to the labor involved (EPIC is not well structured for this), risk of accidentally leaking PHI, and general motivation (getting hold of useful data is the bread and butter for career researchers).

Re: Her Various Symptoms Seemed Unrelated, Then One Doctor Put It All Together

#63

My guess is the doctors who don't spend extra time trying to solve the case probably shouldn't be paid for the time separately as is being suggested here. It would appear to me that they have already lost the innate curiosity (if they ever had it) that made them want to become doctors in the first place. Or they're not confident enough in their ability. Doctors are already paid substantially compared to most other pr…

The idea that we should count on people to spend additional time on their job for free because they enjoy it seems overly idealistic. Sure, such people exist, but the easiest way to incentivize more time on a job is to just pay people accordingly.

Re: Her Various Symptoms Seemed Unrelated, Then One Doctor Put It All Together

#64
post #24

TLDR: It was Schnitzler Syndrome, a rare autoimmune disease. Clickbait titles and suspense-novel narrative structures in articles like this really annoy me for some reason. Just get to the point.

Right; it's like someone has watched too many episodes of House and thinks that's how doctors are/should be.

In this case it is the other way around. AFAIK Dr. Sanders was the inspiration for House.

Re: Her Various Symptoms Seemed Unrelated, Then One Doctor Put It All Together

#65
post #33

Earlier quoted context omitted.

Article said a dermatologist was consulted early on and who failed to make the connection. Doesn’t support your ascertion.

Of course it is possible to miss the diagnosis. My point was that this is not an obscure disease that a dermatologist would not know about.

But what you actually said is this:

if the patient had been seen by a dermatologist I would be surprised if this would have been missed.

I was diagnosed in my mid thirties with a genetic disorder. It is a more recently recognized milder manifestation of a well known condition. Prior to that, I was basically treated like a hypochondriac and routinely accused of being lazy.

I have read a bit about the difficulty in getting a proper diagnosis. It is routine for people to get treated like they are nuts because the doctors do not immediately have the answer. This winds up being incredibly threatening. It puts you in a position of fearing for both your freedom and your life if you keep talking about your symptoms and keep trying to find an answer, while knowing that not getting an answer may well kill you.

When I had been on antibiotics for several weeks straight with no diagnosis, I expressed my concern that I could die if they couldn't find the answer. The doctor asked if I would like a psych referral. My legitimate concern that I could die in the face of being deathly ill and doctors failing to readily diagnose it was treated like I was merely being neurotic and needed therapy.

Doctors frequently do a terrible job of identifying anything that is at all obscure and they treat patients in a way that makes it both very challenging and genuinely threatening to even try to get a proper diagnosis. I did all in my power to not wind up hospitalized because I was relying heavily on home remedies, like hot baths, to keep my symptoms down to a dull roar. I was convinced that ending up hospitalized would deny me the ability to do that and would be the death of me because doctors can be such assholes at times.

After finally getting a diagnosis, I began growing stronger and healthier. I had always been sickly and did a lot of self care. I now had an explanation as to why I was always sick and it was very empowering.

People with my condition typically get regular checkups with a specialist four times a year. As I grew stronger, my doctor began scheduling me fewer checkups and expressed zero curiosity as to how on earth this was happening when it is supposed to be impossible. When I moved because I was getting divorced and could not afford to remain in California, I did not bother to try to find a new specialist. I can manage my condition better than a doctor can and I didn't want the hassle when doctors don't really want to see me anyway because, I guess, I'm too competent to be a desirable patient.

One outgrowth of that: people on the internet conclude I am some nutcase rabidly rejecting conventional treatment. Doctors did not really want to see me. I no longer need a physician's care. But good luck explaining that to legions of internet strangers who are quick to judge and have no desire to be confused with the facts.

If you have an obscure condition, it is not unusual to know more about it than most general practitioners will. This fact is not at all respected by the general public. Claiming you know more gets pissed all over in internet discussion.

The system does an incredibly poor job of serving most people with obscure conditions. Given the wealth of information and tools available today, I find it appalling that this is so.

Re: Her Various Symptoms Seemed Unrelated, Then One Doctor Put It All Together

#66

TLDR: It was Schnitzler Syndrome, a rare autoimmune disease. Clickbait titles and suspense-novel narrative structures in articles like this really annoy me for some reason. Just get to the point.

I call this the Ira Glass effect. At some point in the 2000s everything became This American Life.

Re: Her Various Symptoms Seemed Unrelated, Then One Doctor Put It All Together

#67
post #7
post #4

Earlier quoted context omitted.

Is there a way to actually request a specific doctor have some time dedicated to figuring your case out at your expense? i.e. "Please do more troubleshooting for me above what insurance pays." I like your idea - but I fear the industry might have already ruled it out. -edit- Granted, I've done this in my own life by going to specialists at their own offices/outside of a hospital or medical group.

Unfortunately, no. Your doctor is contractually bound to the insurer’s fee structure; they can’t take an extra penny off of you. You’d have to go to someone that doesn’t take your insurance at all (or just don’t tell them you have that insurance). The side effect of all this, honestly, is that doctors stop learning how to turn off 7-minute-mode. When it comes to very serious problems, it pays to go to a practice that…

Glad I live in a country with a free health service.

Re: Her Various Symptoms Seemed Unrelated, Then One Doctor Put It All Together

#68
post #5
post #2

> As for Huls, he is finishing up his fellowship at the hospital this summer. Wherever he ends up, he is certain he will find new cases to challenge his curiosity, cases he hopes to solve. No, he won’t, because only early stage residents are given the freedom from economic realities to spend hours digging and thinking through records. Docs aren’t paid for their time, nor even for results - and their employers (read:…

Why doctor? It's the most expensive part of your healthcare. But it can be trainee/researcher/AI. Which could be absolutely out of expensive healthcare system. Service which you could buy for additional cost from company which has good guess/prediction ratio based on input parameters from doctor. Service which could be in any part of the world.

I have often thought that the Freestyle Chess model (a variation of Advanced Chess https://en.wikipedia.org/wiki/Advanced_Chess ) could be applied to medical diagnosis.

Create a team consisting of one or more human doctors with a medical diagnostic AI.

From the article it sounds to me that a lot of the research could have been done by an AI, with the human doctors making the final decision on the "best" diagnosis.

Re: Her Various Symptoms Seemed Unrelated, Then One Doctor Put It All Together

#69
post #13

> Huls hadn’t heard of Schnitzler syndrome, either. He came upon it by using the database PubMed to look for a disease that matched the patient’s symptoms. He made a list of her symptoms and abnormalities. To get the full picture, he combed through her earlier electronic medical records, now archived in an old electronic warehouse, and found that her symptoms had started maybe a decade earlier. Then he looked for a d…

> Is this database open? If so, anyone in the same situation as the daughter in this article could spend the hours, rather than hoping a professional will.

I've done this with various doctors, trying to figure out what the hell is wrong with me. In my experience, as soon as you start telling them they just think you're a crazy hypochondriac who sends too much time on the internet.

Re: Her Various Symptoms Seemed Unrelated, Then One Doctor Put It All Together

#70
I have zero medical expertise, but it sounds like this situation could be improved with software. Given a database that contains an exhaustive list of every illness and symptoms:

    illness      symptom     diagnosis_symptom_set
    -------      -------     ----------------------
    id           id          id
    name         name        symptom_id (FK->symptom.id)
                             illness_id (FK->illness.id)
             

    (Pseudo SQL)

    SELECT diagnosis.name as name 
    FROM diagnosis_symptom_set diagnosis_sympt
    JOIN illness diagnosis ON diagnosis_sympt.illness_id = diagnosis.id 
    WHERE symptom.name in (hives, chills, weight-loss, .....)

This will at least give a patient awareness of what has been tried/tested and what remains, possibly saving them months or years.
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