Do you miss diagnosis?
Started by WaterAvatar
Become a BI physiatrist. You will have plenty of opportunities to be the first to catch undiagnosed dvts/PEs, fractures, hydrocephalus, peripheral nerve injuries, subdural hematomas, strokes, tumors hiding bleeds (rare, but I've caught it thrice), seizures, neuroendocrine disorders, etc. Admittedly, most diagnoses are made prior to the patient's admission to us, but BI Medicine affords a regular opportunity to make diagnoses on secondary AND primary conditions related to your patients.
This is one of the reasons I was drawn to the field, and remains an exciting and interesting aspect of remaining in this subspecialty.
i was worried a bit about that as well before getting into the field, but, thats really not how it as. now, im not a "BI" physiatrist, but i think i also make plenty of diagnoses that PCPs, orthos, neurosurgeons etc., miss or misdiagnose. i really dont think its a problem
That's not the case at all on the physical medicine end. We've made tons of diagnoses in sports and spine clinic, as well as general msk clinic. And when you do EMGs, you're certainly making new diagnoses all the time.
Even on rehab wards, you have to be able to diagnose problems that result from the CVA/TBI/SCI.
More times than not, I'm the first one to tell someone what's wrong with their back, neck, feet, whatever. That and the fact that I take the time to explain the why/how it came about and what their options are makes them very grateful. I often hear them say I'm the first one to take the time to explain things to them.
PM&R doesn't have to a be a tertiary specialty, being the bottom of the food chain or the "bottom feeders." I see many patients within days or weeks of injury or onset. Many have had no real treatment yet, let alone a diagnosis.
Do EMG and you'll be making new diagnoses all the time (see the MSK & EMG Forum).
I also do a lot of confirmatory diagnostics, such as hip and shoulder joint blocks under fluoro to prove they are causing the patients' pain or not.
MSK ultrasound is an up-and-coming area we can capitalize on potentially.
I keep trying to shape my practice more and more towards diagnostics. For my ortho group, I do all the EMGs (10-11/week ave), shoulder and hip and other joint blocks and pre-MRI arthrograms (5-6/week ave, we have our own MRI), plus get all the spine work to diagnose and treat.
My ultimate goal would be doing 20 EMG's per week and 10 - 15 hours of diagnostic injections. 30 - 35 hours per week and I would be able to retire early. As our practice grows, that may not be an unrealistic possibility. 😎
PM&R doesn't have to a be a tertiary specialty, being the bottom of the food chain or the "bottom feeders." I see many patients within days or weeks of injury or onset. Many have had no real treatment yet, let alone a diagnosis.
Do EMG and you'll be making new diagnoses all the time (see the MSK & EMG Forum).
I also do a lot of confirmatory diagnostics, such as hip and shoulder joint blocks under fluoro to prove they are causing the patients' pain or not.
MSK ultrasound is an up-and-coming area we can capitalize on potentially.
I keep trying to shape my practice more and more towards diagnostics. For my ortho group, I do all the EMGs (10-11/week ave), shoulder and hip and other joint blocks and pre-MRI arthrograms (5-6/week ave, we have our own MRI), plus get all the spine work to diagnose and treat.
My ultimate goal would be doing 20 EMG's per week and 10 - 15 hours of diagnostic injections. 30 - 35 hours per week and I would be able to retire early. As our practice grows, that may not be an unrealistic possibility. 😎
Ditto all above.
You'll be amazed what walks through the door of a pain clinic diagnosed as "fibromyalgia" by PCP's. I've been the first to diagnose critical cervical stenosis, myasthenia gravis, unstable 2-column spinal fractures (!), diabetic lumbosacral radiculoplexus neuropathy (moments away from being operated on for compressive radiculopathy), benign cramp-fasisculation syndrome, RLS, obstructive and central apnea, femoro-acetabular impingement syndrome (thanks to MN1 for opening my eyes to this one during residency), buckets of peripheral neuropathy (hypothyroid, diabetic, toxi-metabolic), MS, multiple myeloma (can you say "M" spike?"), cancer, unrecognized brain injuries (mislabeled as "fibro-fog" whatever the hell that is!) and strokes.
I haven't yet diagnosed ALS or monomelic amyotrophy...but I'm looking for it!
The first rule in medicine is never assume the last doc got it right. Go from there.
I think that what you're seeing is the difference between community and academic practice. Academic physiatry is definitely the furthest "down-stream." You get out in the community and you get patients a little eariler in their continuum of care and you can really make some interesting diagnoses.
You'll be amazed what walks through the door of a pain clinic diagnosed as "fibromyalgia" by PCP's. I've been the first to diagnose critical cervical stenosis, myasthenia gravis, unstable 2-column spinal fractures (!), diabetic lumbosacral radiculoplexus neuropathy (moments away from being operated on for compressive radiculopathy), benign cramp-fasisculation syndrome, RLS, obstructive and central apnea, femoro-acetabular impingement syndrome (thanks to MN1 for opening my eyes to this one during residency), buckets of peripheral neuropathy (hypothyroid, diabetic, toxi-metabolic), MS, multiple myeloma (can you say "M" spike?"), cancer, unrecognized brain injuries (mislabeled as "fibro-fog" whatever the hell that is!) and strokes.
I haven't yet diagnosed ALS or monomelic amyotrophy...but I'm looking for it!
The first rule in medicine is never assume the last doc got it right. Go from there.
I think that what you're seeing is the difference between community and academic practice. Academic physiatry is definitely the furthest "down-stream." You get out in the community and you get patients a little eariler in their continuum of care and you can really make some interesting diagnoses.
In defense of academic physiatry - some of us are still decent clinicians. The practice of academic physiatry is as diverse as the practice of community physiatry. Inpatient, outpatient, brain, SCI, musculoskeletal, neuromuscular, pain, cancer, amputee, etc.
Speaking as someone in the specialized niche of academic outpatient neuromuscular rehab, I make interesting diagnoses all the time: Kennedys disease (referral from a neurologist to r/o LEMS). Radiation induced sarcoma involving the proximal median nerve (breast cancer patient everyone thought her symptoms were due to radiation plexopathy since repeated plexus MRIs were normal the tumor was more downstream and the plexus MRIs missed it). Referral for unsteadiness needs PT by a cardiologist thin, elderly woman, workup by numerous neurologists unremarkable. My eval/work up showed a bone density T-score of -7.0 No wonder she felt unstable! Surprisingly, no one thought to screen/check for osteoporosis in this woman who underwent a parathyroidectomy as a teenager and hadnt eaten a single dairy product in over 50 years (lactose intolerant).
To the OP - Your ability to diagnose will depend on your practice, your referral sources, and your own diagnostic acumen. You'll make bread and butter diagnoses. You'll catch a few zebras along the way. Sometimes you will see a patient with fresh symptoms and get to work them up from scratch. Other times you will see patients that have had workups, but they're not getting better thats why theyre coming to see you. As drusso said never assume the last doc got it right.
Bottom line - We diagnose in PM&R. Often, we can treat too.
It has been gratifying to me to see my colleagues with different areas of specialization chiming in regarding the opportunities to "make the call" and be the first to identify/diagnose and treat problems among our patients. (I hope my colleagues didn't infer that physiatrists outside of BI don't diagnose--I just couldn't resist giving my subspecialty a plug in an area [dx] that is a strength for us.)
As drusso said-never assume the last doc got it right. (Well said.)
As ludicolo said-We diagnose in PM&R. Often we can treat too. (Amen.)
Interventionists take the general low back or neck diagnoses and identify specific pain generators. Once identified, we can often address the offending structure with our ever-expanding bag of tricks, or, in the alternative, disperse them to our neurosurgery, ortho spine, psychiatry, or neurology colleagues.
great replies.. thanks guys
