Sunday, September 10, 2006

The Doctor of Last Resort - New York Times

Dr. David Podell entered the exam room and introduced himself to the patient. He knew this middle-aged woman was depending on him to finally solve the mystery of her illness. She had already been to three doctors, and none had any answers for her. In such cases, when the patient has already seen other doctors before arriving at your door, you need to approach the case with a different mind-set — with different assumptions. You know, for example, that whatever this patient has, it isn’t going to be obvious. Maybe it’s an unusual disease, known best by specialists, or perhaps it’s an unusual presentation of a more common illness. In any case, it won’t be routine.

The woman spoke in a slow, husky vibrato. “I can remember clear as day when it all began,” she said. “It was just over a year ago. I woke up and felt like my legs were on fire.” She had always been healthy, but that morning the pain had been so severe that she could hardly walk. And she had felt weak — especially in her left leg.

The cough started a few weeks later, she told him. At first it was a dry cough. Then she started to bring up blood. Recently she felt out of breath with even slight exertion.This morning, she had to stop and rest during the short walk from the parking lot to his office.

She had seen her internist throughout all this. He sent her to a neurologist for the burning and weakness and then a pulmonologist when the cough appeared. Despite their best efforts, the pain, weakness and shortness of breath persisted. She had been through dozens of tests and scans and a couple of courses of antibiotics, but the specialists were no more successful than her own doctor.

Finally her internist sent her to Podell, a rheumatologist. Such doctors, specialists in diseases of the connective tissue, are often a last resort when patients develop symptoms involving different systems and a diagnosis is elusive. Because connective tissues are found throughout the body, complex, multisystem illnesses are the rheumatologists’ bread and butter.

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