American College of Physicians: Internal Medicine — Doctors for Adults ®

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Time is a hurdle on path to right diagnosis

From the March ACP Internist, copyright © 2009 by the American College of Physicians

Janet Colwell

Our cover stories this month focus on two diagnoses that are often missed during primary care visits: intimate partner violence (IPV) and Sjögren’s syndrome. While they are very different, both illustrate how the time constraints of a typical office visit might derail the cognitive process and lead physicians off track. Fifteen or 20 minutes may allow enough time to ask the right questions, but it doesn’t leave much time to think.

The signs of IPV—unexplained bruises or an overly protective spouse, for example—may seem self-evident, but in practice it can be difficult to know when to suspect IPV or whether to question a patient. It helps to have a standard protocol for when and how to do basic screening, notes Senior Writer Jessica Berthold in her article. Experts advise asking very specific questions, for example, and looking for less obvious red flags, such as chronic pain, depression or anxiety.

Sjögren’s syndrome is a difficult diagnosis largely because of its similarity to other autoimmune diseases, such as lupus, rheumatoid arthritis and fibromyalgia, and its often vague symptoms, including tiredness and very dry skin. In addition, lack of awareness has been a big problem, experts pointed out. As writer Bonnie Darves reports, it has been known to take up to eight years to correctly diagnosis Sjögren’s, but that time can be cut significantly if a physician has the syndrome on his or her radar screen in the first place and can make an educated decision about whether to pursue the necessary workups.

Given the time, most internists relish diagnostic challenges, evidenced by the enthusiastic response we’ve received to our MKSAP quizzes and clinical case studies. Remember, you can submit your most memorable cases of missed or challenging diagnoses to our Mindful Medicine columnists, Jerome Groopman, FACP, and Pamela Hartzband, FACP, for consideration in future columns.

We look forward to hearing your comments and suggestions. Write to us anytime.

Sincerely,
Janet Colwell

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