The Elephant, the Blind Men, and the Medical Family Tree
On a Facebook live yesterday on my “You’ve Got the Power” show, someone brought up the idea of how to avoid blind alleys in diagnosis. That brought up the story of the blind men and the elephant, which is how I’ve explained missed diagnoses to medical students, residents, and fellows through the years. We also talked about the medical family tree. Let’s explore these topics.
Blind Alleys in Medical Diagnosis
On a Facebook live, a patient wanted me to discuss the topic of wasted time on diagnostic blind alleys. Basically, that patients who have difficult to diagnose problems often find themselves getting all sorts of work-ups from all sorts of specialists that never show much. They get frustrated and want to know why this happens.
The scenario usually goes something like this:
- A patient sees a specialist
- A “the million-dollar workup” ensues – meaning the doctor doesn’t know what’s wrong with the patient and just begins reflexively ordering more and more tests.
- These tests come back normal or indeterminate
- The patient is sent to a new specialist
Let’s dive into a concrete example. Patients with upper neck instability can have rapid heart rate (tachycardia). This is believed to be caused by irritation of the vagus nerve which normally acts like the brakes on the heart rate. However, patients with this condition will often get full cardiac work-ups for that tachycardia. Is that warranted?
For example, it might be reasonable to get certain cardiac tests like an EKG or Holter monitor. However, extensive testing probably makes no sense. In addition, if the tachycardia can be expected as a result of the neck injury, nothing more than a minimal work-up is indicated. The problem is that the cardiologist doesn’t know that the patient’s neck injury can cause this issue, so they plow ahead.
The Blind Men and the Elephant
The problem illustrated above is also described by the story of the blind men and the elephant that’s told in medical education to illustrate a point. Three blind men are lead into a room with an elephant. One is placed at the tail, one at the leg, and one at the trunk. Each man is asked to independently describe what he feels. The man at the tail says he has a rope, the man at the leg says he has a tree, and the man at the trunk thinks he has a fire hose.
The moral of the story is that our hyper-specialized medical care system is like the three blind men. Meaning the cardiologist above doesn’t know anything about the neck and they certainly don’t know anything about upper neck instability, so they treat this tachycardia as if it has a likely heart origin. Hence this story is used to help students and young doctors to understand that their job is to have the 30,000-foot view (the elephant) at all times and not lose sight of the forest for the trees. Meaning, how can they find one over-arching medical problem that explains all of the symptoms and not just one.
The Medical Family Tree
Someone also asked the question of why many physicians can be so clueless when it comes to complex musculoskeletal (MSK) diagnoses. The reason? The medical specialty family tree has two main branches. One major branch that includes internal medicine and neurology is based on medical diagnosis and focused on medications. The other branch has specialties based on anatomical diagnosis with specialties like PMR, orthopedics, and radiology.
Getting back to our example above, a doctor who sees a diagnosis like upper neck instability who comes from a medication focused part of that tree just doesn’t have a box in which to place a diagnosis like this. This would require a 3-D anatomical understanding of how the neck is put together which isn’t really what they studied. Instead, they studied how various medications impact various diseases.
One patient on my Facebook Live show described this as getting gaslighted. In fact, it can feel like that when the doctor doesn’t have any idea of how your symptoms and exam point to a diagnosis. Again, that often depends on which part of the medical family tree from which they sprung. It also helps if they’ve seen patients like you before.
The Other Side of the Diagnosis Coin
Equally frustrating for patients can be when a diagnosis gets applied, but it’s the wrong one. I’ve seen this happen many times. Patients who are frustrated from falling through all of the cracks in the medical care system finally get someone to give them a diagnosis. However, later when we see them, it’s clearly the wrong one that focused on a few symptoms like the elephant and the blind men. However, they are fiercely protective of that diagnosis as it’s the only life raft that’s been thrown their way in years. This makes sense and I don’t blame them, but sometimes getting them on the right diagnosis life raft can be really hard for the doctor.
An example of this that we’ve seen this past year is Eagle syndrome. This is a problem where a little bone that sticks off the bottom of the skull (styloid process) is too long. The theory is that this can wreak havoc and lead to everything from neck and throat pain to compression of various nerves or blood vessels in the neck. The problem is that the symptoms of this disorder often overlap with many others including the upper neck instability in our example above. In addition, only 4% of patients that have a long styloid bone will have confirmed symptoms from that bone. However, some patients who have been told they have this disorder want that bone surgically cut. The problem? It connects to important ligaments and muscles that can help their upper neck stay stable, so cutting it can cause more instability problems.
My Facebook Live Show
Every Friday and Monday at 1 pm MST/12 pm PST/3 pm EST Jason Deitch and I go over a different regenerative medicine topic. We also answer any question thrown at us. On Mondays, we’re on the Centeno-Schultz Facebook page and on Friday’s on the Regenexx page.
The upshot? You now know the story of three blind men and the elephant and that medical specialties live on different branches of a family tree. All of that often explains why patients with hard to diagnose MSK issues get so frustrated. So hang in there!