Vindication feels nice.
Some time ago I saw a young woman patient who’d been feeling crappy for about a year. She’d seen several docs but hadn’t managed to get a diagnosis. She described an amazing array of diffuse, hard-to-characterize symptoms, and my initial concern was that I was going to have a hard time finding anything on this one, too. The situation was worsened by the fact that she had some clear ideas about possible diagnoses, which was coloring her description of the problem to me. So to get a clear viewpoint, I first had to look past her bias.
After some initial testing turned up nothing, I suggested that I needed to see information about her symptoms in much, much more detail. I asked her to keep a diary of her symptoms, her diet, her sleep, and her activities for two weeks. When I received the diary, I went over it with a fine-tooth comb and had a flash of inspiration – her symptoms had a fairly clear diurnal variation, with one set of problems in the morning and a different set in the afternoon/evening. And, the afternoon/evening symptoms seemed to vary depending on her behavior that morning, in particular with how much salt she ate.
I concluded she may have an adrenal problem causing increased cortisol and mineralocorticoid activity. Sent her for some initial testing and sure enough, her morning cortisol was about twice normal. So I sent her off to the endocrinologist to see what was going on.
Well, he was really rude to her. He laughed in her face, basically, and told her that her cortisol lab was high because she’s a hysterical little girl who got excited over the test. He told her he’d order a backup test (24-hour urine cortisol) to “prove” that she doesn’t have this problem, and sent her home. She was pretty upset.
But today the urine cortisol came back and … guess what! It’s nearly three times higher than the upper limit of normal. Of course, his first line of action is to tell her something must’ve been wrong with the test, and ask her to repeat it… but meanwhile he’s also ordered the additional tests (the ones my little lab can’t do) that will be needed assuming the original test is valid. Which it will be. She’ll get the diagnosis and get the appropriate workup and treatment to take care of the problem.
Why did he laugh at her? Well, the symptoms caused by high cortisol are eventually very destructive on the body. Someone with high cortisol will develop obesity, a hump of fat on their upper back, a widened, moon-shaped face, severe acne, and hair growth in inappropriate places on the body. My patient has gained weight, seen increased acne, and feels like she’s seen some changes in the shape of her face, but these issues are all still very early – she hasn’t gained enough to be obese, hasn’t got enough acne to be disfigured, etc. So she doesn’t “look” like she has the problem.
And I say, what’s wrong with believing a patient who knows her body is behaving differently, doing a diligent workup, and finding the problem before it leaves her permanently altered?
So I’m feeling pleased that the patient will get the care she needs, smug that I identified the diagnosis on the basis of some very subtle clues – clues that several other doctors failed to see – and, well, rather guilty that I’m actively pursuing jobs other than medicine.