Testing One-Two-Three

The patient’s spiking fevers had lasted over two weeks, and all efforts to diagnose an infection (the most common cause of fever) had yielded nothing.  She was admitted to the hospital for further workup, and late one evening, I was asked to see her, as the rheumatologist on call.  The electronic health record showed a normal admission physical exam (except for her temperature) and dozens of normal blood tests.  The only abnormality was a markedly elevated erythrocyte sedimentation rate, which is a nonspecific indicator of inflammation– it can be high in infections, malignancies, autoimmune diseases etc. and did not narrow down the diagnosis by much.  The inpatient ward team’s primary question for me was:  Out of all the numerous lab tests associated with rheumatologic diseases, which should they order?  ANA?  SSA/B?  RF?  ANCA?  aCCP?  What’s the best rheum test to diagnose an autoimmune disease? they earnestly inquired on the consult request.

After taking a detailed history of her illness, I looked at her skin, her mouth, nose, ears, felt for lymph nodes, listened to her heart and lungs, pressed on her abdomen– most are routine features of the physical exam– without finding anything abnormal.  It seemed the admission exam was accurate, and it was going to be a long evening.  Then I threw back the bed covers, to take a look at the legs.  The abnormal finding was immediately obvious:  her right foot was pointing at the ceiling, while the left foot was pointing at the door.  Hard as she tried (with me cheering her on), she could not point it upwards.  How long had that been going on?  Oh, about two weeks, she said– was it important?

She had what is called a foot-drop!  I went back to the electronic record, which made no mention of it (“Neuro, nonfocal,” it said).  And yet her conspicuous foot-drop, a result of a condition known as mononeuritis multiplex, led to the correct diagnosis of vasculitis (after a biopsy):  PAN, polyarteritis nodosa.  Long before the biopsy result came back, the patient’s fever had already resolved on treatment begun later that night.  Further blood tests did not contribute to her care; the “best rheum test,” it turned out, was throwing back the bed covers.

What brought this episode to mind was an article by Dr. Abraham Verghese in today’s NY Times, How Tech Can Turn Doctors Into Clerical Workers, in which he warns of the downside of electronic health records and artificial intelligence, in terms of mistakes made, the temptation to cut corners by simply making a keyboard click, the decline in the interpersonal aspect of patient care, and physician burnout.  It is human nature, I suppose, to seek the fastest path to a solution; to order more and more tests rather than look at the patient’s feet; and to write the daily progress note electronically by replicating the previous day’s note (with minor additions), assuming that the admission note had not missed anything.  In 2018, we seem to rely less on ourselves, our senses, our analytical skills, and more on all our ingenious inventions– our computer algorithms, antibody screens, DNA sequences, cell counters, all our technology– and in this way, we become subservient to them.

In the dystopian society of the Fourth World trilogy, machines use A.I. to make the diagnoses and prescribe the treatments.  Here’s an excerpt from the first novel, Fourth World:

“The patient, W.P., is a 64-year-old transportation executive who complains of severe, sharp pains and tightness in all of his muscles, of eight months duration.”  Kai began his presentation, reading from his open da-disc to the small group of interns, who were supervised that Friday by Dr. Hol Chan. W.P. was sitting hunched over on the hard examining table, wrapped in a short white cellulose gown, hands spread on his exposed knees.  He had been through this ritual ordeal so many times before. Less than a meter away, his wife sat stiffly upright on a short metal step stool. Standing just to her left, Benn observed her jaw muscles, clenching and unclenching. A state of agitation. Her middle and distal knuckles showed the bony enlargement of mild osteoarthritis.  There was a tiny growth on her forehead, which he diagnosed as a seborrheic keratosis; the Probot would have concurred. Because the room had been designed to accommodate only the patient and one physician, Dr. Chan and her interns were forced to crowd around.

“He is previously healthy, except for a very brief period of PsySoc rehab in his twenties, and his social and family histories are non-contributory.”  Kai glanced nervously at Dr. Chan, who, having heard Kai’s presentations before, watched him with an expression of deep concern as she activated the wall projection.  Kai continued, “I have put W.P. through the Probot twice, and both times the results were identical: signals of tissue injury or regeneration, inflammation, pre-mutagenesis and metabolic derangement are completely absent.  Epigenetic expression, including at the micro-RNA level, is normal. Risk loci mapping and haplotype structure are unremarkable. You can see on the next screen that the central and peripheral chi are not in any way obstructed.  I entered the patient’s history, systems review, family history, physical exam and lab data into the analyzer and found no matching diagnosis. And so, without a suitable coding of his diagnosis, there is no way to initiate the billing process.”

Dr. Chan, studying the wall screen, nodded in agreement.

Kai looked up from his da-disc and shrugged.  “In fact, W.P. is perfectly healthy, even though obviously he is persisting in his illness behavior.”



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