Sunday, September 22, 2019

Do I Have Diverticulitis?

I have been treating diverticulitis for 30 years the same way.  When I suspect that a patient has this diagnosis, I prescribe antibiotics.  This has been the standard treatment for this disorder for decades.
I have found that diverticulitis is a slippery entity that has two trap doors waiting for physicians to fall through.

 It is an easy task to miss the diagnosis.  Every physician has done this.

The diagnosis can be erroneously assigned to a patient.  Every physician has done this.

Recognize that the phrase ‘every physician has done this’ includes me.
The diagnosis can be elusive as there is no diagnostic test that secures the diagnosis.  The technology tsunami has covered the medical landscape, as it has run over so many other spheres in our society.  Doctors and patients increasingly rely upon ‘the numbers’.  Want proof?  Do you think there are many physicians today who can actually plug a stethoscope into their ears and hear, let aloneunderstand all of those clickety-clackety heart sounds?  And, if they do, they order an echocardiogram anyway. 

Hey, what's this new fangled contraption?

The medical community and those we serve are hyperfocused on objective data - stuff that can be measured.  Here are 3 examples of seemingly reasonable questions that I believe often miss the mark.  

What did the CAT scan show?  
Did the tumor marker decrease?   
Is my carotid arteries screening test normal?  

A more relevant question, such as, how is the patient doing?, is ignored or relegated to a lower priority status.  Who cares if the tumor marker goes down if the patient doesn’t feel any better? 

So, when diverticulitis is a consideration, a physician actually has to act like a doctor.  Sure, a CAT scan can be consistent with diverticulitis, but many other conditions can precisely mimic this CAT scan appearance.  So, the physician has to make a ‘clinical diagnosis’ of diverticulitis.  This means that the doctor must analyze all of the data – your symptoms, the labs, radiology results – and then make a judgment.  A common error is when the diagnosis is prematurely made based primarily on the CAT scan, without weighing other factors.  A clinical diagnosis of diverticulitis can also be made without a CAT scan or laboratory data.  Yes, the doctor can actually perform old fashion doctoring, which has become rather quaint these days.

In my practice, many patients who come to me complaining that they are experiencing a ‘flare’ of their diverticulitis are mistaken.  There is some other explanation for their stomach pain.  Or, the patient may state that the pain is identical to a prior episode of diverticulitis, but often the original diagnosis of diverticulitis was incorrect or uncertain.  Yes, I admit again there is always the chance the patient is right and I am wrong, but hopefully my decades of training and experience are worth something. 

My points above are certainly not restricted to diverticulitis.  They cross into every medical specialty.   Technology and objective data too often are wag the dog.  Who do you want evaluating your medical symptoms, a physician or Alexa?

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