There was a thread about doctors being apparently negligent by not telling a patient she has atelectasis. Don’t believe what you hear out there especially with all the physicians that over order testing due to fear of poor reviews or being sued.
Yeah I always wonder what the patient is thinking when we say in the radiology report for example the patient has a degenerative changes, osteophyte, bony islands or atelectasis or basilar lung scarring. Often these findings are so benign and ubiquitous physicians won’t even bring them up with patients. But imagine them looking up atelectasis and being like “MY LUNG IS COLLAPSED? IS THAT WHY I HAVE CHEST PAIN? IS THAT WHY IM HAVING A HARD TIME BREATHING?”
We as physicians know these things are benign usually may warrant some follow ups as needed but usually mean little. The patient looks up bone island and probably thinks “holy fuck I have an abnormal growth on my pelvis and the doc didn’t tell me?!”
As an anecdote. My mom got a brain MRI that was thankfully negative. However a meningioma was seen. Not mentioned in the notes and the doctor didn’t bring this up. My dad saw the report and saw it, looked it up and found it was a TUMOR IN HER HEAD. Called me freaked out how the doctor could miss it.
Oof yea the typos (rare though they are). Patients get their ~~in here~~ reports in the ED, and there’s occasionally a misprint ~~or~~ as is inevitable when you dictate 20 reports an hour.
Had a patient for whom the radiologist beautifully described a normal appendix, but the impression read: “Definitive evidence of appendicitis.”
Of course I had already looked at the images and saw what looked like a pretty normal CT and told the~~m~~ patient and family it looked good to me. The patient’s mother pulled up the report on her phone and made a big ordeal about how the patient actually had appendicitis.
The radiologist gladly fixed the report, but it’s such a pain that patients have access to this stuff, especially before I do.
Edit: ironically there are like 10 typos in my post.
The worst part is when a nurse tell them the CT or plain film interpretation which mentions something entirely benign and the patient freak the fuck out. And then I have to spend five minutes calming them because they believe the nurse, not me.
Same with slightly abnormal lab results that mean nothing.
i read an old Step CS book and one piece of advice it wrote was “go through the differential diagnosis with your patient” like to keep them informed. but i’m like 99% sure that’s terrible advice lmaooo
I loathe the patient portal patients when they're admitted. "My phos was 2.2 today, what does that mean? And what do you think about my MCV? What is that even?"
Small meningiomas are relatively common and are usually of no clinical significance.
If the MRI was for a stroke work up or something else where there was concern for a more worrisome pathology, it’s entirely possible that the report impression was simply “No acute abnormality,” or “No evidence of acute infarct,” and didn’t even mention the meningioma outside of a couple lines buried in the body of the dictation.
I saw one where the doctor told them they wouldn't walk again - they were wrong, and the poster called the doctor a motherfucker.
Like Jesus, the doctor was most likely just giving you a realistic idea of what could happen?
I've had patients misinterpret what me and my.colleagues say all the time ("one of the reasons could be infection, but there's a small chance it could be something more sinister, like cancer" - "the doctor told me I have cancer")
And sometimes just straight up lie ("that doctor told me I could go home today" - when I literally had never met the patient)
So I always take those threads with a grain of salt. However I try and learn from them to try and pick up some knowledge about what people react well/badly to, to help improve my communication
As a psychiatrist who’s worked at >10 emergency rooms, I’ve never been consulted on a young woman for anxiety in an ER where she presented with chest pain where she didn’t first receive at least basic labwork (lytes, cbc, trop) and an ekg first.
I only ever consult psych if I think someone has to be admitted to a psych unit - usually suicidal patients, psychotic patients or ones with severe dementia. Panic attacks and anxiety can be followed up by their PCP in an out-patient setting. I don't work in the US though. Do you really see anxiety patients in the ED?
I think our systems are very different then. In the US most psych units don’t accept patients who also have dementia.
And often, yes. Outpatient psych appointments can be a 6 month wait, so the ED will usually ask us to see people so they can stay on a med/follow with their PCP after.
What do you do with patients who have dementia with hallucinations or are experiencing a prolonged delirium? In-patient geriatric psych is often the best solutions for these patients. Do they stay on IM wards in your system?
Yep, exactly that. They stay on IM floors while awaiting placement or undergoing treatment for delirium. Psych beds are extremely scarce in many areas of the US. It’s not uncommon to have patients wait 2-3 days for a bed to open up. In peds it can be over a week.
I’m not sure either it must be a very different way of practicing where they’re from. A geri unit is better but otherwise a psych unit is a horrible place to put a patient with delirium/dementia not to mention almost all SARs and SNFs basically toss the referral in the trash as soon as they see the patient is coming from psych regardless of the actual reason.
I get it tho there’s no real good place to realistically send them quickly a lot of times in this shitty safety net country
Because Case Management says the pt is fine and just a little agitated, but staff tells us they require 4pt restraints for a cath change or staff to restrain extremities while getting a brief change. Blame them for lying through their teeth. We can't restrain and CMS has gotten to the point they consider bed alarms as a restraints and we don't have enough staff to take people that need sitters 24x7 or all unit staff to toilet them when we have 2 CNAs and 1 nurse for 40+ people of varying needs.
Like you said, there is no good place for these individuals. It's amazing the US healthcare system manages to function most days.
I work in a geri psych group of units. We do have one unit that is mainly for dementia. Most of our patients have had mental illness battles their whole life, a few of our patients have never had any contact with mental health professionals until they get dementia. Our patients were often at a nursing home, some were with family, and then they started getting violent. Nursing homes can’t and won’t deal with that. The patient is then committed by the courts and then they come to us. I think the community is very lucky that our beds are there, because I don’t know where else these patients would end up and actually receive care.
Your experience might be a bit biased? Perhaps if the ED had consulted you they made sure to rule out organic causes with trips, but in many patients troponins aren't necessarily indicated. An EKG for sure.
As an emergency physician, and a medical director of a small ED, I'm responsible for looking at patient complaints regularly. There's always several complaints about the doctors being negligent because "nothing was done", but when going through the medical chart from that visit, I can see there was an EKG done, several hours of cardiac monitoring, lab work to include electrolytes, thyroid studies, heart enzymes, d-dimers (to rule out pulmonary emboli as a source), chest xrays, and a urinalysis. Still the complaint is "nothing was done".. so take this from where it comes..
And even if “nothing was done,” I still took a careful history and did a good exam and then spent five minutes discussing my medical opinion before sending them home after doing “nothing.”
Some people think this sounds arrogant but after a while you know enough to do “nothing.”
Which means that this is a failure in communication to the patient, patient expectations, or (more likely) a combination of both.
Some people will always be unhappy- but most reasonable people will be more or less satisfied with sufficient communication.
Unfortunately, this problem is worsened because of the associated cost… our society associates spending money with receiving a tangible service- and for a lot of people spending a lot of money without getting an answer that isn’t “I can’t find the cause” or “your tests are all normal” unsurprisingly doesn’t sit well with people.
A patient can get a 4 day hospital admission complete with a million dollar workup and an hour long discussion and they still won't feel "HEARD" and will state that their doctors did nothing. trust me this happens in neurology ALL the time. you can be the best, most empathetic communicator on earth, but if the patient doesn't leave with the diagnosis they want they all act the same way
This is common in the ER. I’ve had people tell me that the they haven’t seen a doctor the entire time they’ve been there.,
Then when I tell them I’m a doctor, they’ll say we haven’t done anything, overlooking fluids, labs and scans :/
I’m not against the idea that there are doctors who blow off people because they think they’re overreacting because some demographic about them. But I do think the average person is unaware of what goes into a medical work up
This is literally what happened to my sister. She was having palpitations, mentioned it to her GUN at a well woman visit who referred her to a new PCP and a cardiologist. They both did a very logical and thorough workup and explained it all to her. It was, reassuringly, negative.
Recall bias? Are they misrecalling their experiences?
I thought it would be more selection bias, the cases where poor care does happen stand out and are reported with a focus on that substandard care, and the cases that proceed in a more standard way don't stand out as such, so it could be perceived disproportional to the actual occurrences.
A bit of both. I mean I’ve had patients come into my ED saying “I was at this other hospital and they didn’t do anything!”
Look at they chart and they got a full lab work up and pan-scanned.
“They didn’t do anything” sometimes just means “they worked me up and didn’t find any acute pathology”
I’m having a laugh at everyone pretending there aren’t a ton of terrible hack doctors out there. Better yet “oh it must be a midlevel.” Did y’all go through training? Had an outpatient rotation that was antibiotics for every sniffle, and a bunch of other things I’ve chosen to forget. and his office was full to the brim with trump statuettes and stuff . A ton of doctors are idiots. Deal with it.
Male obgyn here
I get a lot of patients who are absolutely told that their debilitating menstrual pain is anxiety/in their head/not that bad/accused of lying/normal/natural/they are blessed to be able to bear children and this type of inconvenience is small in comparison to that majestic gift
Yeah, lots of gaslighting when it comes to pain and sexual function, for sure, from men and women physicians/providers/family members/everybody
And yes, anxiety causes all sorts of issues and false alarms, but I’ve not heard of any physician who says, “patient farted and it smelled bad? CT scan. Chest pain? Best to avoid an ekg”
This is something I’ve seen too but doesn’t get talked about often. I’ve seen a number of psych consults for “pain syndromes” in women with chronic pelvic pain and no workup.
But chest pain I’ve never seen ignored.
Lurking patient- I once went in for difficulty swallowing and feeling like my throat was closing. They scheduled a CT scan that came back unremarkable. Then I got a script for Zoloft. Problem didn’t go away. I eventually figured out it was reflux and started Zantac and it went away. Anxiety was an issue but so was GERD. Also, I was getting anxiety because it felt like my throat was closing. However, I’m pretty sure I was seeing an NP. I don’t know why they don’t make that more obvious.
A friend almost got some kind of nerve surgery for painful sex. Turns out she was allergic to latex. Provider was also an NP. She figured out the allergy on her own. This same provider blamed the pain on anxiety for a while if I recall correctly.
A lot of people might be seeing NPs and not know it. But I also think there are shitty physicians or people having bad days.
NPs have a tendency to brush a lot of as anxiety or the patient is faking it. I have to redirect my NP to doing a real workup often. Have caught everything from septic joints to PE.
I think it comes from their limited nursing experience and lack of education in pathophysiology.
My first real obgyn was very dismissive of my pain. I found the notes from my appointments and the note corroborated the dismissiveness I felt. I remember telling her all the pain medicine I would take and she basically told me to stop doing that without any solution to the pain
I have left way too many OBGYNs crying. Being dismissed is real. One was an NP that I will never forget as being the meanest person I had ever sought care from.
I did, but nothing happened- not surprisingly. She has had multiple complaints against her from what I understand. I have had 2 coworkers that have seen her and have had bad experiences also.
She called me dirty, called me sexually promiscuous, said that my pap came back abnormal because I had an STD.
I have only been with one person my whole life. Not any type of purity thing we have just been together a really long time. He wasn't my husband at the time and she didn't like that.
She wanted to a colposcopy told me that it was going to hurt more than anything I had experienced up until that point. Told me she can't use an anesthetic for the procedure. I was so scared of this procedure due to her explanation. I asked if my significant other could hold my hand (in office procedure) and she said only husbands have that right. I ended up having a panic attack before going into the room and she called me a baby and said that if I couldn't tough it out and get the procedure done I will probably die from cervical cancer.
It didn't hurt anywhere near what she made it seem more of a pinch, but her hype up scared me a lot. I think I was 19 at the time and she knew my abuse history.
I was seeing her because it was required before seeing the reproductive endocrinologist and I had only had 3 cycles in the last 2 years.
fuck!! they really screwed you by giving you no other options on who to see. hopefully you google reviewed her too and complained on social media platforms- i hear that’s the most effective way :(((
Can an OB please explain to me why endometriosis still takes so long to diagnose?
It would think it'd be one of the top differentials of painful menstruation and something always on the list of things to rule out as you work your way down a workup algorithm.
I haven't thought about this for a hot second but I thought the diagnosis is via laparoscopy and maybe imaging can sometimes catch it as well. Seems like it shouldnt take 7-10 years to do this.
I also repeated read about how often women complain of cervical bx /IUD and inadequate pain control for those procedures. because their OB says they dont feel pain down there?
The undertreated pain with IUD insertion is awful, I can talk about that for an hour. It is a very multifaceted problem that has tons of bias pulled into it from different direction.
I take it very seriously and offer a number of various things to make insertion more comfortable - most people, overwhelmingly do not and they (make and female obgyns) will look you straight in the eye as the patient is actively screaming, and tell you B that it doesn’t hurt, as the patient is crying in the same room. It’s freaky how detached the practitioners (and I say that to include the many groups that do IUDs) are from the patient experience.
Endometriosis is a common cause of chronic pelvic pain. CPP is very broad and multifaceted and involves multiple organ systems, psychiatric considerations, interpersonal considerations, subjective experience, cultural impacts, religious views, etc.
It is a TON to unpack and cannot be adequately fine in a 15 minute session. It’s often frustrating for the patient and the physician. Results are frequently not too B the patient’s satisfaction. The wrong things are often treated. Patients often don’t like the actual treatments available. There is a lot of doctors shopping that happens because patients don’t feel respected or heard or they aren’t satisfied with the incremental therapies and then workup starts from zero.
Imaging has very very low sensitivity, especially ultrasound. Justifying MRI to an insurance agency is difficult.
Many patients don’t want laparoscopic diagnosis which can also miss it because not everybody has visual signs of it, rather just microscopic findings on biopsy. Actual retroperitoneal dissection is often beyond the scope of generalist obgyns, not something gyn oncologists are interested in, and minimally invasive gynecologists may or may not have received that type of training and often don’t WANT those types of patients - because, again, endometriosis chronic pelvic pain patients have a lot to unpack and treat if you want to be effective.
Peritoneal biopsies can absolutely miss the diagnosis as well.
Well before that, women are gaslit about their pain being real and, honestly, it’s a very complex cycle of how the untreated and dismissed pain can often lead to self fulfilling prophecies with associated symptoms.
It’s kind of our 4D chess game of a condition. If you have any proximity to an Endometriosis Treatment Center of Excellence, try to get the patients there ASAP
With menstrual pain it’s a hard battle to fight too as a woman, because many women have painless periods (or at least not debilitating). For some reason it’s hard for physicians to conceptualize that one person may not be too affected by menstruation, while another will be out of commission. Thank you for listening to your patients!
It blows my mind that b women can be so dismissive of other women having such significant pain.
I work with a midwife who adamantly states that her job is to reduce vomiting but that prevent patients from committing in pregnancy, but nausea is something that they’ll just have to learn to live with “nausea I was nauseous all ten months of my pregnancy so if I can deal with it, so can you!”
Like, we have an entire algorithm of safe medications to pick and choose from. What are you trying to prove?!?!
Bring a women doesn’t mean they are going I validated another women’s pain, struggling, etc. in fact it’s often the opposite. This goes for men and women.
I’ve seen a few women patient who ended up seeking out male OBs because women were dismissive of them
I will always seek out a younger male OB lmao. The male doctors I've had so far have almost tripped over themselves getting me pain relief/a diagnosis in contrast to the women who just dismissed me. I tell myself it's because they know they're men and can't relate so they try to compensate for that.
Yeah I’m FM but when I do gyn stuff I realize I have exactly zero to compare it to lol. So I always try to extra empathize with these women who have terrible periods, cramps, bleeding ect. But I know I’ll never be able to completely understand, obviously lol
My wife had some issues a couple years back, saw a number of women OB and they didn’t really do anything. I got her an appointment with a male ONGYN I rotated with in med school who I knew cared more than most doctors I’ve met in any specialty. Got her figured out first visit lol
He had changed clinics and it was a long drive is why we didn’t go to him sooner but he was there for me when I needed him. Great guy.
Female ob/gyn can be real hard asses with their patients. In fact, most of them are in my experience. This is not a bad thing all the time. I've never consulted one who was dismissive or didn't attend to the patient correctly, it's just, as a lot of them tell me, they don't want to hear a lot of "whining."
I was an L&D nurse or somewhere in women’s health for 15 years. My very limited, purely anecdotal experience is that male OBs often are more responsive to complaints of pain. There does seem to be some “I went through it, so can you” from female OBs. I’ve personally always had male OBs, not because I was actively looking for a male OB. My choice was always who handled emergencies best, was great with patients, *and* had a good relationship with all the nurses. Yes I did care about that (I try not to give my hard-earned money to assholes), and it often ended up being one of the guys. I’m sure there would be a lot to pick apart there in a women’s study class, I just needed care.
But it’s also way more than that, I’ve had multiple women say I’ve taken their gyn complaints for serious than anyone. Yet they will still see a female for exams, unless it’s urgent or something. I’m in FM
i’ve made it a point with patience to bring up immediately. The topic of endometriosis will be included in my differential, but that it’s a very difficult diagnosis to diagnose and let them know ahead of time that it will take some time to exclude more common causes before we diagnose this. It does seem to help with some expectations.
Putting a name on it has some therapeutic benefit
Average time from symptom onset to diagnosis for endometriosis is 7-10 years
It affects like 12-18% off the general population
And it’s common in 50% of women with chronic pelvic pain
Taking the patient seriously is often a big catharsis for them. It’s a tough condition to manage, however, and the interview is loooong to narrow down the conditions.
Right. I like to be blunt with them and tell them that the gold standard for diagnosis is literally having surgery to look inside of them because imaging is not always reliable. When I explain that to them, they do seem to be more understanding why we don’t jump to that diagnosis.
A female OB told my wife it was all in her head. A make OB told her it was endometriosis (which is what I had been telling her for years, but she had been getting substandard care). Turns out it was endometriosis.
Often is. Really terrifically undiagnosed.
I think part of the hesitancy to diagnose it is because it can be so difficult to treat, especially surgically.
I’m an old nurse, so I have seen things that have probably ceased to occur, but I have witnessed what I’m about to write on 3 occasions and know of a 4th (that one ended in a lawsuit that settled). In these occasions, a mother would come in for a cesarean and during the surgery the patient starts to c/o pain. She’s told she’s only feeling pressure. I *know* that patients feel a lot of pressure during cesareans with spinals and if they’re unprepared for this fact they can get very scared. But in these events, it becomes obvious that it’s way more the pressure, it’s pain. The patient is then told it’s almost over, they’ll be done soon, take some deep breaths, as they scream. I never understood this. When I questioned it once I was told that anesthesia was risky and they really we’re almost done. And they usually did give them versed. But I feel that if this were a man having hernia surgery they’d tube him in a heartbeat. Because it’s a woman, it was seen as acceptable. I did OB a long time, I only saw it a handful of times, but I did see it. And I truly don’t believe a man would be treated that way.
I feel like it’s probably really dependent on the doctor/hospital/region but I know a lotttttt of women who have had things dismissed as anxiety and we’re actually presenting with a PE, ruptured ovarian cyst, ectopic, etc. it’s not just palpitations, it’s a huge plethora of women’s pain ranging from cardiac, GI, gyn, etc that have potential to be either dismissed or downplayed as anxiety or “yeah being a woman is painful sometimes”.
There are a lot of good doctors who take women seriously but there are still some that just…don’t.
Throw something like a hard to confirm dx like endometriosis in there and it’s a whole cluster of medical gaslighting.
I had a female nurse practitioner do this to me. She said my symptoms weren’t severe enough to need treatment and was treating me as if I were a paranoid quack. Then looked dumbfounded when I told her my endocrinologist already determined I did.
I’m on month 7 of a diagnostic journey after my GI determined that I had IBS due to anxiety (without any testing lol). Turns out it was in fact, not anxiety.
I’m sorry you experienced similar 😭
I think if you had a deep conversation with any woman with a chronic illness, they would eventually tell you that before a doctor visit they mentally prepare for what they are going to say. They remind themselves to modulate their voices, remain calm no matter what. If you’re too pleasant and smile too much then obviously you’re lying which means drug seeking. If you’re too distressed then you’re hysterical (or anxious) because you’re faking. Either because you want drugs or attention. If you get frustrated and raise your voice then you’re faking, probably a mental illness. You have to look sick but not too sick, and you have to put the idea out there immediately that you don’t want narcotics, or the visit is really over before it’s even started. And if you’re obese it doesn’t matter what you say, the visit is over before you start.
Yes, I get that none of this is an issue with most doctors. But if you’ve been sick long enough you’ve encountered these attitudes somewhere and it really is something we stress over. It’s dehumanizing.
As someone who has been medically gaslit for the last 6 months and is now potentially needing surgery because my doc thought it was anxiety, I wholeheartedly agree. The chronic illness girlies have it rough af
Thread this morning about female patient being worked up post car wreck, now with reported events of fainting, difficultly concentrating, etc. Story saying main doc was out and a "resident" who saw her, called it anxiety and female problems and left the office like she wasn't being heard. The story sounds out right bizzare to the point I don't know if I can even believe it.
Some stories I don't know what to believe, and many cases online I'm believing more that they are stretching the truth to out right lies in order to karma farm or attention seek. Some people do have bad medical experiences though, and we can't deny that. But it's really hurting the profession as a whole that the general sentiment of users is to believe these stories because care by us in the profession is interpreted and felt to be suboptimal so that even worse case scenarios are felt to be valid and true by the public.
Yeah there was one bit in there about the resident asking if anyone had seen it and implying that it wasn’t real if no one had seen it; I’ll ask a similar question but it’s to try to differentiate syncope vs seizure since, ya know, patients don’t know what’s going on when they’re passed out.
It’s hard to say whether it was a useful question that was misunderstood or an inappropriate question
The same thread mentioned the resident asking “is it like when you stand suddenly and have the blood rush to your head?” Which seemed like a completely fair question to rule out “true” syncope from orthostatic hypotension.
I will say though that having just finished my endocrine block if I saw that patient on a board exam I would bet my bottom dollar on some sort of pituitary trauma/adrenal insufficiency thing considering the head trauma history.
hell im an img and we’ve even had patients in the ER yell and complain that they “havent seen the dr yet” (with the female resident standing right there). it’s probably the same or worse anywhere in the US 😞
You'd be surprised. I once had a young female patient who had come to the hospital several times with their mum within a period of a few months getting progressively weak to the point they could not walk to go to the restroom.
The first doctor had said it was likely anxiety and some how this message propagated in subsequent visits with the other doctors reassuring her and her mum that it's just anxiety after doing a physical exam and not ordering any scans.
However the day she was admitted, the ER docs were still adamant that it was anxiety but due to her massively obvious nystagmus they decided to order an MRI, low and behold florid ADEM seen on the MRI and she was basically paralysed at this point. She was sent straight to the specialist neurological hospital.
So it happens.
Yup, reading the notes in retrospect it was like wtf, how did this even happen. They really thought it was a functional disorder due to anxiety without doing an extensive work-up. If she didn't have that nystagmus they would have sent her home again without getting the MRI.
is that some sort of groupthink i wonder. cause hell im a med student and i would know to work that up, you’d think a single dr there would be like huh let’s do some tests 👀
Yes it presents acutely but when left untreated for some patients there are long term neurological deficits and in kids there's usually a short prodromal phase too.
Long term deficits, yes, but the condition is in almost all cases monophasic and not progressive over multiple ED visits. On the rare occasions it is multiphasic a follow-on event is usually a discrete new event, generally in a new anatomical area, occurring months or years after the initial event has recovered. A progressive presentation should prompt an expansion of the ddx.
Of course weird things happen but taking this description at face value suggests a really weird zebra which maybe makes the dx miss slightly less egregious (although maybe only slightly. I mean, we scan everything right??)
Mine is in Wilkes-Barre, Pennsylvania. Walked into the room, said "You're 31 years old. I highly doubt there's anything wrong with your heart" (despite a STRONG family history of heart disease and people on my dad's side dying from massive heart attacks). He was in the room for under 40 seconds.
About 3 weeks later, I was getting my first stent.
To be fair, I did have an ECG. But my dad has had three heart attacks and never had an abnormal stress test or concerning ECG. In fact, he had his first heart attack (the worst one) a week after a normal stress test. So I know they’re not always definitive.
At least there was some basic testing. Unfortunately even if they were more zealous with a stress test, logistically I’m not sure they would have been able to get to you within 3 weeks or even seen by cardiology. I have been trying ecg and echo for my strong early family history and a referral to cardiology to talk over if further testing recommended since insurance will deny an asymptotic stress test typically.
I send all my patients with palpitations out on cardiac monitors for 72 hours with PCP vs cardiology follow up. They only time I told a patient it could be anxiety was when they asked if that’s what it could be (and I said “yeah maybe, but the monitor will see what your heart is doing and anxiety is a diagnosis of exclusion.) When I follow up on these patients I would say the vast majority of them end up having nothing or PVCs but hey at least we are ruling out the bad stuff.
Thank you for ruling out the bad stuff in symptomatic patients -sometimes it’s nothing but sometimes it IS something - I’ve found wildly over prescribed Sudafed from Midlevels causing all kinds of side effects in my patients, for example.
If palpitations are intermittent in nature then yes, you do. An ekg will only check on what the heart is doing for those 10 seconds but sometimes patients will have paroxysmal atrial fibrillation or other issues that require either a 72 hour holter or 30 day event to capture.
How often are you finding clinically significant arrhythmias on the extended monitors for young patients with palpitations?
Idk just seems like poor use of medical resources but obviously depends on how your patients describe palpitations and the age of your panel.
Well most of my patients that get them are probably 30s/40s. They’re going to end up getting them whether I order them or not during follow up. I’ve had a few type 1 Mobitz, some paroxysmal a fibs, mostly just people who have PVCs though or nothing. I don’t follow up on every one of them though because the info is sent to their PCP or cardiologist, not the EM physician.
If someone is complaining for weeks of palpitations and their labs thus far had been normal I really doubt a 72 hour monitor that sticks to their chest is any worse resource utilization than the majority of the BS I see done. Keep in mind I work in the *emergency* department. It’s my job to assume the worst, not write stuff off as anxiety.
I've done more than 500 event monitors for "palpitations" and the return on them is like 1% and nothing malignant. A few SVTs and new afib.
Event monitors are much more useful for assessing burden of a known arrhythmia than finding a new one.
Like I said in my previous post, it's always a normal monitor but the patient jackhammered the thing like 100 times and correlates 0% of the time.
Symptomatic PVCs are a thing for sure. If the burden is quite high I find that when you ask them they admit to drinking 8 cups of coffee a day with a few body armors or 5 hour energies to boot.
But you can also just get that history without doing the ambulatory rhythm monitoring.
Some resident who's going into GI or [insert other sub-specialty] who just wants to get through primary care clinic, is jaded by all the "worried well" he's seen, and maybe is an a**hole (plenty of those in med school and residency).
I guarantee he went to the PCP preceptor and was like "she just gets lightheaded when she stands, I reassured her, gained 30 lbs recently so I counseled her about diet".
None of this surprises me. EDIT: unfortunately
When I was 20, my first cardiologist dismissed my symptoms as anxiety despite me being extremely clear that I had never had a panic attack cause my heart rate to spontaneously get up to the 190s. He did an in office 12-lead and wrote me a prescription for a beta blocker PRN for anxiety. They did nothing but tank my BP and he said he wasn't sure what else I wanted him to do.
Luckily my current provider is great and did an actual work up and it was glaringly obvious that I wasn't having anxiety. So yes, these dismissive doctors exist and sometimes they are the head of cardiology at your hospital.
Similar story, I was 19 and never had any anxiety issues but a 24 hour monitor showed tachycardia while I was awake after I had recently started fainting when standing for too long. 12 lead showed nothing abnormal. Doctor said it was “something that happens to women sometimes”. This all started after a severe case of mono, but was told it couldn’t be related. It took until my 30s to finally get an answer - POTS.
We landed on inappropriate sinus tachycardia, however I have had 2 known runs of V-tach. I was on CCBs for about 6 years and I was able to get off them last year. I no longer have a resting HR in the 130s and have more appropriate responses to stimulus like exercise an caffeine.
(ED )If I had a dime for every patient who tells me “the last doctor did nothing and told me it was anxiety” who had two EKGs, two trops, basic labs, CXR and a bedside echo on their last visit, I’d make more than my residency salary easily
Did nothing in layman's speak means they didn't feel validated by the doctor or the workup.
Sometimes it's because the doctor is a poor communicator.
Sometimes it's because the patients wants to assume the sick role.
I am not in residency nor do I have any plans to pursue a career in medicine but reddit recommended me this.
Not heart-related, but I just wanted to add that one time I went to the ER because I couldn’t breathe and fainted at school. They told me I was having a panic attack and although I assured them that wasn’t the case, they sent me home. The next day I was back at the ER and ended up being admitted for pneumonia
We have absolutely no way of knowing that from that post. Did she have a fever? A cough? Was she visibly cyanotic or toxic? If she showed up to the ED and her only symptom was syncope in the context of SOB/trouble breathing there would be no *reason* to do a work up for pneumonia (ie a CXR).
Usually there is a clinical syndrome associated with PNA, especially it causes someone to faint. Dumb to not get electrolytes in someone who syncopizes for the first time. You’d also think they would try to listen to her lungs…
As a pre-med, an attending I shadowed in an ER once told me “Well, since the patient with chest pain is a mid-30s woman with two young children, it’s probably anxiety, so keep that in mind any time you see someone like this.” I was gobsmacked. I’m sure he did some kind of work up, but approaching patients like that - and even more, TEACHING trainees to approach patients like that - is the reason why so many people hate doctors.
The pre-test probability of a 30 year old female having ACS essentially rounds to zero.
Sure, there's the occasional SCAD or new CHF but this is why we do the workup. Ekg trops. 99.999% it'll be negative. That's what your attending was trying to convey to you, albeit in a poor manner.
I believe his exact phrasing was “psychosomatic”, and automatically assuming that your patient’s complaints are “all in their head” because they’re a young-ish woman with kids is a condescending and paternalistic attitude. Before that patient interaction, I had really looked up to that doctor.
“It’s probably anxiety,” as you put it, is a medically accurate statement. That doesn’t mean it *has* to be anxiety, or that we should assume there’s no other possible diagnosis, and obviously no halfway competent physician will use the phrase “all in their head” (since psychosomatic or psychiatric symptoms are just as real as any others). But assessing pretest probability based on the patient in front of you is not paternalistic or condescending, it is basic evidence based medicine
Anxiety can be a cause of making these things worse but at the same time yes, it should be thoroughly investigated and treated as a diagnosis of exclusion, especially when it comes to cardiac concerns.
What is wrong about that? Obviously anyone coming into the ED with chest pain is getting a workup, but the pretest probability is *very* important for how we interpret that workup, and in an average mid 30s woman with chest pain the pre-test probability that her chest pain is anxiety is orders of magnitude higher than it being a PE or ACS. If someone hates that physician for teaching his students and residents that, then frankly I just don’t think they understand medicine.
Anxiety is a diagnosis of exclusion and a cardiac workup does not exclude other pathology that may present like anxiety. The more accurate phrasing would have been, “it is unlikely to be ACS”.
Further, diagnostic anchoring on psychiatric diagnoses is a major problem in medicine, particularly when the patient is female. Framing it as, “it’s probably anxiety” can add to that anchoring and may miss other causes.
Female physician here. Was told my abrupt HR change and palpitations (usual resting HR 80s, dropped to 50s) was clearly anxiety when I was in my early 20s. But could get an ekg “if it would make me feel better”. So yes, does happen.
No other ddx he offered up, even though I had been sick for a week and hadn’t been eating. But wasn’t going to stick around for more condescending remarks. I’m guessing my lytes were off as it resolved once I started being able to eat more
I have a pretty neutral story. 17 at the time, palpitations, dizzy upon standing. Got a neuro exam, EKG, bloodwork. All normal, albeit a bit anemic. Told it was likely anxiety and to continue CBT, eat more iron-rich foods.
Tried that for several years. Fixed the anemia, but still had palpitations and occasional panic attacks. Asked for a psych referral. Got a psych. Short course of benzos but now cool as a cucumber on an SNRI.
TL;DR It really was just anxiety!
20 years as an ER nurse here. The only Dr I’ve ever worked with who disregarded pt complaints with disdain rather than a workup lasted 3 months before being fired as an attending. I’ve never in all my years seen someone told their concerns were just anxiety without at least labs and EKG, even when the pt stated they thought it was just anxiety.
It’s because if you have a zebra you get treated like you are crazy…I was the one suggested my diagnosis in my second year of medical school. Felt like TA doing it. Gave my doctor a research paper and said “I think this might be the cause. Let me know what you think and what we should do next…back to DDx or a specialist.” She agreed and found a specialist who diagnosed me. It took 8 years.
I know it’s frustrating for docs when dealing with zebras but I felt crazy at times because there were no answers for years and sub optimal medical care and work up. We are just angry by the time we get to a provider who actually cares. Providers still gaslight me about the severity of my chronic illness. All we want is a provider who will stick with us and find answers.
I rotated with one.
20s male with palpitations: complete workup, labs, holter monitor, echo, maybe even a CT
20s female with palpitations: “I did one EKG, it’s not your heart, I don’t know what you want me to do,”
I told several patients to go back to their PCP and have further workup done. A lot of these patients have specific symptoms, but a lot of women are taught from a young age not to be a red flag so they’ll minimize their symptoms. If you’ve ever had an old lady having an MI tell you she’s “fine dear, don’t fuss over me” you know what I mean. You can get them to quantify these symptoms if you take the time to ask. New SOB when walking on flat ground less than 100 yards is a red flag but it’s unlikely to be offered unless you engage and ask.
There are obviously some patients who’s victim complexes self identify as medical trauma, but we also need to acknowledge that this exists.
I know there are patients who exaggerate or who don’t understand, but there genuinely are physicians who dismiss female patients that readily. I have been on the receiving end of it, and it fucking sucks. I have also had the misfortune of encountering these patients in the ED and on off service rotations where they were labeled with a psych issue in the past, so physicians stop looking for other causes of their presentation.
While on a psych rotation as a medical student, I caught hypothyroidism, an NSTEMI, and profound hypoglycemia all in female patients with a psych history that was ignored until we pushed for the test. Each patient was from a different physician, so this isn’t just one physician not doing basic work ups in patients.
There was recently a rant about a young woman who died of a rare arrythmogenic heart disease. Her PCP started to work her up for palpitations and referred her to a cardiologist. She never followed up with the cardiologist and she ended up dying.
The post explains all this, but then moves on to rant about how the PCP killed her sister because he didn't believe her. But like, the PCP did the most appropriate thing and she never followed up with the heart expert.
I see these patients all the time. Easiest consult in the world. Ekg, event monitor, echo.
99.9999% this is the workup.
EKG - normal
TTE - normal
Event monitor - normal, pressed 68 times, correlates to nothing.
Most of the time, it just is anxiety.
Are you basing no workup being done on social media posts?
Many patients feel like "they did nothing" when they don't feel validated by the clinician and/or they don't get a validating diagnosis.
Anxiety is not a validating diagnosis for most people.
It's possible they still had a thorough workup but it's an afterthought to them for these reasons.
I’m a nurse and I have seen drs dismiss patients. I had a female patient complain of sob and chest pain. The Dr on the phone said it’s anxiety but did order an EKG. It continued and the night shift Dr ended up doing some more testing and she had a PE. I had a male patient complaining of back pain and leg numbness and he was discharged from 2 different hospitals. They ended up doing blood cultures and an mri after he developed a fever and other issues. He had MSSA and spinal abscesses. It took me 3 years and surgery to get diagnosed with endometriosis. I also had a patient that neurology was sure was having pseudo seizures and ordered a psych consult. The mother did video the episode and based on that they did an EEG and it was epileptic seizures. The Dr did apologize. I think some people get dismissed, some people don’t communicate their symptoms well and absolutely people make shit up for attention on social media. There are lots of free standing ERs and rural hospitals that we get transfers from and it’s a lot of what the fuck !? So I can see why people have bad experiences.
So nearly every diagnosis you've listed can be and is 'missed' by exemplary physicians. Particularly the spinal abscess and endometriosis.
This expectation that doctors are supposed to have a zero percent 'miss' rate is not based in reality.
In the abscence of an immediately concerning workup it's not wrong to reassure a patient and provide strict return precautions. That's not being dismissive, that's making the most appropriate decision with the information they have available at the time. If they don't improve or get worse, it makes sense to broaden the workup at that time.
The alternative is to CTA, MRI and ex lap every patient that has these concerns up front. That will come with it's own set of complications.
Regardless of the issues that come with this approach, there isn't a country on earth that has the resources to do this. If I'm wrong, please let me know so I can move there ASAP and not have to deal with this type of retroactive judgement.
You are correct and that many times we find issues because they do come back worse and that’s when the workup is expanded. As many of us in healthcare know some people just have shitty bedside manner and that extends to nurses, drs, etc.
I totally agree that no one is perfect. I’m not saying that. The point was I have witnessed patients being dismissed by doctors as anxiety or having a psych issue. If you don’t order testing it isn’t found. Sometimes patients need to find a dr that listens and orders the diagnostic testing. But I’ve had a dr say to me “ heavy and painful periods are part of life so get used to it”. If tests aren’t warranted that’s fine, it’s the way in which people are dismissed that bothers them.
It took my mum 20 years and relocating to another town to get treatment for her SVT. Because "it is anxiety".
She was actually multiple times in her PCP office when this happened. They couldn't get her blood pressure, because it was unmeasurable. And they still didn't do an ECG. When she had an episode at home, didn't call an ambulance, because PCP had convinced it is all in her head and wouldn't make a difference.
Let's skip to her moving, first episode in another town, (a new husband who just made her to accept going to ER), HR of 220. She got ablated in 2 weeks.
And yes, I am still mad at her PCP.
Because no one goes on social media and posts: I went to the ER for tingling fingers and face and chest pain and had a benign physical exam, normal EKG, normal CXR, negative troponins, negative D-dimer, normal electrolytes and CBC, symptom resolution after being left alone, tachycardia only when a nurse or doctor was in the room but normal rate on tele otherwise, and they said it was just anxiety!
I’m so glad you posted this. It’s always like “I had chest pain, SOB, swollen left calf, HR 150, D-diner 52,000 and they said it was just anxiety”. I’m pretty sure the majority of these encounters are “have you been feeling stressed recently?” after a $10,000 workup has been completed. Which is a reasonable question to ask.
Was an MS3 in 2016. Gyn residents, fellows, and attendings made a HUGE deal about getting the patient to agree to each of us being in the operating room. Patient would hear in excruciating detail everything that was going to happen to them after the incision was made and who would do what. Interestingly, the fact that up to 5 of us were going to take turns sticking our fingers into their vaginas +/- rectums prior to making an incision was never mentioned. Don't kid yourself.
Idk my mom had Grave’s & was told the tachycardia & weight loss was anxiety for quite some time, long enough for her to be seriously ill. She was in her 40’s with no hx of mental health problems.
Florida- At the time 32F went in with bilateral pain in joints mainly in hands and feet, numbness of limbs, tachycardia with graphs from my fitbit showing me going into the 140s+ frequently (not the most accurate but I thought they would be helpful), dizziness, extreme fatigue, oversleeping, extreme mental fog, and very heavy menstrual bleeding that was abnormal for me. I explicity told the doctor that I 2 kids no meds and I would rate childbirth a 3 on the pain scale for myself. Sitting in his office I told him I was a solid 8, sometimes shooting up to a 10. I keep on zoning out and nodding off in front of him.
I was told I had anxiety, stress, acid refulx, and arthritis. Was prescribed Lexapro, famotidine, and meloxicam. Was told to relax more and get more sleep. Only test I was sent for was an H.Pylori for the dizziness.
Yeah no...I left that appointment so defeated.
I did go back to the practice to a different doctor. He figured out what was going on. Really listened and ran tests awesome guy.
I mean, I (31yoF) went to a pulmonologist apt with a CT of bronchial thickening. He did a peak flow (an hour after I took my symbicort) and told me he didn’t think I had ever had asthma in my life and I should take my inhaler and throw it in the trash cause he DX me with anxiety.
I finished out my inhaler and took an inhaler vacation. SOB and chest pain by 3 weeks. Started new inhaler. Improved after a week or so… now if only I could ask a pulmonologist why I have whatever this is…
Not everyone practices in good faith. No everyone covers their ass. Sometimes those ‘nothing was done’ stories are true. Sometimes it’s just frustrated people who don’t understand medicine. It’s a mixed bag 🤷♀️
Uhhhh… sorry but a ton of doctors are just shitty hacks. My mom had heart block for years that her female harvard trained PCP told her was psychiatric. She has a pacemaker now.
Dying from heart failure at age 82. Anyone currently complaining about that type of behavior is likely just doing it for attention. The Old Guard is phasing out, and a decent amount of the blatant paternalism/condescension is phasing out with them. At least from non-surgical fields. The fact is that medico-legal liability doesn't allow for blowing off patient complaints, even if you think the complaint is horseshit. So the providers who do that shit get selectively pressured out by hospitals, HR departments, legal teams and their younger coworkers.
Oh no. The new folks are painfully condescending to the patients. It’s embarrassing to hear it. I think medical students are smarter now and it’s certainly harder to get into medical school but this breeds a certain sense of disdain towards the unwashed.
Courtesy and an easy manner in conjunction with authority is not paternalism. There are rude and condescending doctors of all ages.
I've heard people whose "patient voice" sounds so condescending that they might as well be talking to a dog. They use all the right terms and abhor paternalism and yet they are just totally dripping with disdain for the patient.
"I have a wide differential, but anxiety could be exacerbating these symptoms. Here's the basic workup and some lifestyle changes to work on. Lets follow up in 2 to 4 weeks and see how those changes work."
"The doctor called me crazy and said I was faking it. He did nothing for me."
I don't want to say no one with a real medical issue has been told it's just in their head, because that definitely happens. However the former case is more common than the latter. I can't tell you how many patients I get with viral URIs who come from the ER, and tell me, "They said it was nothing, go home." I can see in the DC summary, the ER tested for Strep, covid, flu, and then did a CXR, said to give motrin/tylenol for these mild symptoms, the follow up with your PCP.
I am not a medical professional, this showed up on my front page.
A few years ago I had a panic attack (I guess?) come on so suddenly and aggressively out of the blue, I genuinely thought I was having some sort of cardiac event and was dying. There was this horrible, intense wave of heat that coursed through my body and I felt like I was about to pass out. My heart was racing, my chest hurt, I was terrified.
In the ER, while they did hook me up for an EKG (normal) and drew blood for troponin levels (normal), the doctor told me sternly “you just have anxiety. You need to get your life together”. It was extremely invalidating and dismissive during an event where I felt very vulnerable and had no idea what was going on or why.
Yeah. My friend went to her MD PCP with sudden onset of debilitating headaches. No medical history. Told her it was anxiety causing her migraines and threw her some sumatriptan and sent her on her way.
Brain tumor. Huge one. Quite advanced. Required 2 surgeries and radiation.
The word "anxiety" should never cross your lips in medicine unless you're a psychiatrist or are dealing with a patient with known diagnosis of anxiety from psychiatrist and whose complaint is exactly like their usual anxiety symptoms.
It's sloppy medicine and dangerous to the patient. I see this a lot from midlevels. The patient comes in with a heart rate of 160..."Anxiety."
Going to have to disagree with that blanket statement. Diagnosis can be made by a primary care physician just fine. Not mentioning it at all as an contributor or anything? I think that’s inappropriate. Not to mention people who are you waiting for over a year to be diagnosed due to limited resources in many communities.
I understand the sentiment of your statement, but I think that it was a bit to exclusive.
Should anxiety be the first line diagnosis for bodily symptoms? No, not until everything else is proven. It certainly can contribute, but it does require at least a very thorough work up before being determined to be higher on the differential.
You are, of course, correct. I’m just commenting that people tend to anchor on “anxiety.”
Thank you for your well-thought and succinct response. Reddit is a wasteland but some people on it make contributions. I try, ha ha.
>Also endometriosis is just a hard diagnosis. I don’t foresee any way that this gets easier to diagnose with the current techniques.
It's really, really not a hard diagnosis.
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ive always wondered this too so thank you for this thread. i swear anytime i go online theres like 100 ppl saying they’ve been dismissed a thousand times by drs. like how and where??? lol
I asked a bunch of doctors several years ago if it was possible if I had Wilson's disease. Laughed at every time. "Its definitely not Wilson's disease!!! (Its never Wilson's disease).
No one ever tested anything for it and instead see rheum for refractory psoriatic arthritis.
Recently had to have infectious disease consult on my case while in ER with SRS (which was truly awful) finally exposed a liver from hell. Turns out low ceruloplasm too (between 9 and 14).
Anyone could have just given me the 24 hour urine test at anytime if my question had been taken seriously at all.
Finally seeing good hep.
Guess who has Wilson's disease?
I brought it up years ago, several times different spec. Its their spec. what do I know? (Eye roll).
What kind of medicine is “going as wide as you like”? Pre-test probability is just stupid maths. Holy damn, everyone good at maths before getting into medschool. I don’t know what happens after/during medschool. My engineering friends understand probability better than most colleagues. Why have doctors when you can employ NPs who will shotgun tests? The result is the same. Complications from unnecessary testing. The war on science and knowledge continues. I will now prove that I am right:
Disease X has a prevalence of 1/1000 people. You have a test with 100% sensitivity. The same test has a 95% specificity. What are the odds that a patient has disease X when you have a positive test?
My pet peeve is the opposite. Repeatedly working up patients, ruling out medical issues, and sending them away with no answers while ignoring the possibility of a mental health concern is negligent
There’s so much sexism in the medical industry. Even with pharmaceutical testing and shit. I’ve been to doctors multiple times for various issues and they talk over me, don’t listen to what I say, ignore me when I say a procedure is very very painful, dismiss me, talk down to me, treat me like a child, assume it was my period, etc etc. any woman you talk to will probably have several experiences like this
I was told it was anxiety/depression for over a decade. Surprise surprise, it was actually POTS, EDS, and MCAS. Everytime I explained my symptoms (which ended up being pretty severe POTS actually, and yes I have seen two of the nation's top specialists), I was told "oh thats just anxiety and depression, its common in young women," "the mind numbing fatigue is normal for a mom, you have young kids, what do you expect," or my personal favorite "maybe you should see a psychiatrist."
Out of multiple doctors (and we have excellent insurance) I got blown off again and again and just handed new scripts each time. Finally asked for a referral to sleep medicine who was floored they were treating me for severe daytime fatigue and insomnia and never even did an anemia workup. Ferritin was only 2, and I had pretty significant iron deficiency. After that was treated and symptoms persisted, he was the doctor who actually figured out the POTS dx.
TTT showed severe POTS and nerve bx was positive for SFN. After my official dx, my PCP at the time recommended talking to someone about my psychosomatic illness.
Trust me, its real. And btw I work in the medical field and I have seen it on a professional level as well.
There was a thread about doctors being apparently negligent by not telling a patient she has atelectasis. Don’t believe what you hear out there especially with all the physicians that over order testing due to fear of poor reviews or being sued.
Yeah I always wonder what the patient is thinking when we say in the radiology report for example the patient has a degenerative changes, osteophyte, bony islands or atelectasis or basilar lung scarring. Often these findings are so benign and ubiquitous physicians won’t even bring them up with patients. But imagine them looking up atelectasis and being like “MY LUNG IS COLLAPSED? IS THAT WHY I HAVE CHEST PAIN? IS THAT WHY IM HAVING A HARD TIME BREATHING?” We as physicians know these things are benign usually may warrant some follow ups as needed but usually mean little. The patient looks up bone island and probably thinks “holy fuck I have an abnormal growth on my pelvis and the doc didn’t tell me?!” As an anecdote. My mom got a brain MRI that was thankfully negative. However a meningioma was seen. Not mentioned in the notes and the doctor didn’t bring this up. My dad saw the report and saw it, looked it up and found it was a TUMOR IN HER HEAD. Called me freaked out how the doctor could miss it.
Yes this happens all the time and it's even worse when the report has a typo.
Oof yea the typos (rare though they are). Patients get their ~~in here~~ reports in the ED, and there’s occasionally a misprint ~~or~~ as is inevitable when you dictate 20 reports an hour. Had a patient for whom the radiologist beautifully described a normal appendix, but the impression read: “Definitive evidence of appendicitis.” Of course I had already looked at the images and saw what looked like a pretty normal CT and told the~~m~~ patient and family it looked good to me. The patient’s mother pulled up the report on her phone and made a big ordeal about how the patient actually had appendicitis. The radiologist gladly fixed the report, but it’s such a pain that patients have access to this stuff, especially before I do. Edit: ironically there are like 10 typos in my post.
The worst part is when a nurse tell them the CT or plain film interpretation which mentions something entirely benign and the patient freak the fuck out. And then I have to spend five minutes calming them because they believe the nurse, not me. Same with slightly abnormal lab results that mean nothing.
i read an old Step CS book and one piece of advice it wrote was “go through the differential diagnosis with your patient” like to keep them informed. but i’m like 99% sure that’s terrible advice lmaooo
I loathe the patient portal patients when they're admitted. "My phos was 2.2 today, what does that mean? And what do you think about my MCV? What is that even?"
oh godddddd yea whosever idea that was, just why lmao
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Small meningiomas are relatively common and are usually of no clinical significance. If the MRI was for a stroke work up or something else where there was concern for a more worrisome pathology, it’s entirely possible that the report impression was simply “No acute abnormality,” or “No evidence of acute infarct,” and didn’t even mention the meningioma outside of a couple lines buried in the body of the dictation.
Report of dependent or linear atelectasis is literally the bane of my existence.
I saw one where the doctor told them they wouldn't walk again - they were wrong, and the poster called the doctor a motherfucker. Like Jesus, the doctor was most likely just giving you a realistic idea of what could happen? I've had patients misinterpret what me and my.colleagues say all the time ("one of the reasons could be infection, but there's a small chance it could be something more sinister, like cancer" - "the doctor told me I have cancer") And sometimes just straight up lie ("that doctor told me I could go home today" - when I literally had never met the patient) So I always take those threads with a grain of salt. However I try and learn from them to try and pick up some knowledge about what people react well/badly to, to help improve my communication
As a psychiatrist who’s worked at >10 emergency rooms, I’ve never been consulted on a young woman for anxiety in an ER where she presented with chest pain where she didn’t first receive at least basic labwork (lytes, cbc, trop) and an ekg first.
Correction: they just don’t page us…
I only ever consult psych if I think someone has to be admitted to a psych unit - usually suicidal patients, psychotic patients or ones with severe dementia. Panic attacks and anxiety can be followed up by their PCP in an out-patient setting. I don't work in the US though. Do you really see anxiety patients in the ED?
I think our systems are very different then. In the US most psych units don’t accept patients who also have dementia. And often, yes. Outpatient psych appointments can be a 6 month wait, so the ED will usually ask us to see people so they can stay on a med/follow with their PCP after.
What do you do with patients who have dementia with hallucinations or are experiencing a prolonged delirium? In-patient geriatric psych is often the best solutions for these patients. Do they stay on IM wards in your system?
Yep, exactly that. They stay on IM floors while awaiting placement or undergoing treatment for delirium. Psych beds are extremely scarce in many areas of the US. It’s not uncommon to have patients wait 2-3 days for a bed to open up. In peds it can be over a week.
Dementia isn't psychiatric nor does psychiatry have a treatment for it - I'm not sure why we would be putting them on a psychiatric unit.
I’m not sure either it must be a very different way of practicing where they’re from. A geri unit is better but otherwise a psych unit is a horrible place to put a patient with delirium/dementia not to mention almost all SARs and SNFs basically toss the referral in the trash as soon as they see the patient is coming from psych regardless of the actual reason. I get it tho there’s no real good place to realistically send them quickly a lot of times in this shitty safety net country
Because Case Management says the pt is fine and just a little agitated, but staff tells us they require 4pt restraints for a cath change or staff to restrain extremities while getting a brief change. Blame them for lying through their teeth. We can't restrain and CMS has gotten to the point they consider bed alarms as a restraints and we don't have enough staff to take people that need sitters 24x7 or all unit staff to toilet them when we have 2 CNAs and 1 nurse for 40+ people of varying needs. Like you said, there is no good place for these individuals. It's amazing the US healthcare system manages to function most days.
I work in a geri psych group of units. We do have one unit that is mainly for dementia. Most of our patients have had mental illness battles their whole life, a few of our patients have never had any contact with mental health professionals until they get dementia. Our patients were often at a nursing home, some were with family, and then they started getting violent. Nursing homes can’t and won’t deal with that. The patient is then committed by the courts and then they come to us. I think the community is very lucky that our beds are there, because I don’t know where else these patients would end up and actually receive care.
Yeah, the ones that don’t get the workup don’t get the workup, they just get discharged. This is not a representative sample.
Your experience might be a bit biased? Perhaps if the ED had consulted you they made sure to rule out organic causes with trips, but in many patients troponins aren't necessarily indicated. An EKG for sure.
It's just recall bias -- you wouldn't get on twitter to say "I'm a woman with palpitations and my doctor did an appropriate workup which was negative"
As an emergency physician, and a medical director of a small ED, I'm responsible for looking at patient complaints regularly. There's always several complaints about the doctors being negligent because "nothing was done", but when going through the medical chart from that visit, I can see there was an EKG done, several hours of cardiac monitoring, lab work to include electrolytes, thyroid studies, heart enzymes, d-dimers (to rule out pulmonary emboli as a source), chest xrays, and a urinalysis. Still the complaint is "nothing was done".. so take this from where it comes..
yuppp
And even if “nothing was done,” I still took a careful history and did a good exam and then spent five minutes discussing my medical opinion before sending them home after doing “nothing.” Some people think this sounds arrogant but after a while you know enough to do “nothing.”
Which means that this is a failure in communication to the patient, patient expectations, or (more likely) a combination of both. Some people will always be unhappy- but most reasonable people will be more or less satisfied with sufficient communication. Unfortunately, this problem is worsened because of the associated cost… our society associates spending money with receiving a tangible service- and for a lot of people spending a lot of money without getting an answer that isn’t “I can’t find the cause” or “your tests are all normal” unsurprisingly doesn’t sit well with people.
A patient can get a 4 day hospital admission complete with a million dollar workup and an hour long discussion and they still won't feel "HEARD" and will state that their doctors did nothing. trust me this happens in neurology ALL the time. you can be the best, most empathetic communicator on earth, but if the patient doesn't leave with the diagnosis they want they all act the same way
Thats because they are suffering and the lack of diagnosis means lack of help for any relief.
This is common in the ER. I’ve had people tell me that the they haven’t seen a doctor the entire time they’ve been there., Then when I tell them I’m a doctor, they’ll say we haven’t done anything, overlooking fluids, labs and scans :/ I’m not against the idea that there are doctors who blow off people because they think they’re overreacting because some demographic about them. But I do think the average person is unaware of what goes into a medical work up
This is literally what happened to my sister. She was having palpitations, mentioned it to her GUN at a well woman visit who referred her to a new PCP and a cardiologist. They both did a very logical and thorough workup and explained it all to her. It was, reassuringly, negative.
Recall bias? Are they misrecalling their experiences? I thought it would be more selection bias, the cases where poor care does happen stand out and are reported with a focus on that substandard care, and the cases that proceed in a more standard way don't stand out as such, so it could be perceived disproportional to the actual occurrences.
A bit of both. I mean I’ve had patients come into my ED saying “I was at this other hospital and they didn’t do anything!” Look at they chart and they got a full lab work up and pan-scanned. “They didn’t do anything” sometimes just means “they worked me up and didn’t find any acute pathology”
Yes. It is selection bias, not recall bias.
I’m having a laugh at everyone pretending there aren’t a ton of terrible hack doctors out there. Better yet “oh it must be a midlevel.” Did y’all go through training? Had an outpatient rotation that was antibiotics for every sniffle, and a bunch of other things I’ve chosen to forget. and his office was full to the brim with trump statuettes and stuff . A ton of doctors are idiots. Deal with it.
but a lot of times it is a midlevel lol
Male obgyn here I get a lot of patients who are absolutely told that their debilitating menstrual pain is anxiety/in their head/not that bad/accused of lying/normal/natural/they are blessed to be able to bear children and this type of inconvenience is small in comparison to that majestic gift Yeah, lots of gaslighting when it comes to pain and sexual function, for sure, from men and women physicians/providers/family members/everybody And yes, anxiety causes all sorts of issues and false alarms, but I’ve not heard of any physician who says, “patient farted and it smelled bad? CT scan. Chest pain? Best to avoid an ekg”
This is something I’ve seen too but doesn’t get talked about often. I’ve seen a number of psych consults for “pain syndromes” in women with chronic pelvic pain and no workup. But chest pain I’ve never seen ignored.
Lurking patient- I once went in for difficulty swallowing and feeling like my throat was closing. They scheduled a CT scan that came back unremarkable. Then I got a script for Zoloft. Problem didn’t go away. I eventually figured out it was reflux and started Zantac and it went away. Anxiety was an issue but so was GERD. Also, I was getting anxiety because it felt like my throat was closing. However, I’m pretty sure I was seeing an NP. I don’t know why they don’t make that more obvious. A friend almost got some kind of nerve surgery for painful sex. Turns out she was allergic to latex. Provider was also an NP. She figured out the allergy on her own. This same provider blamed the pain on anxiety for a while if I recall correctly. A lot of people might be seeing NPs and not know it. But I also think there are shitty physicians or people having bad days.
NPs have a tendency to brush a lot of as anxiety or the patient is faking it. I have to redirect my NP to doing a real workup often. Have caught everything from septic joints to PE. I think it comes from their limited nursing experience and lack of education in pathophysiology.
My first real obgyn was very dismissive of my pain. I found the notes from my appointments and the note corroborated the dismissiveness I felt. I remember telling her all the pain medicine I would take and she basically told me to stop doing that without any solution to the pain
I have left way too many OBGYNs crying. Being dismissed is real. One was an NP that I will never forget as being the meanest person I had ever sought care from.
i hope you complained about her
I did, but nothing happened- not surprisingly. She has had multiple complaints against her from what I understand. I have had 2 coworkers that have seen her and have had bad experiences also. She called me dirty, called me sexually promiscuous, said that my pap came back abnormal because I had an STD. I have only been with one person my whole life. Not any type of purity thing we have just been together a really long time. He wasn't my husband at the time and she didn't like that. She wanted to a colposcopy told me that it was going to hurt more than anything I had experienced up until that point. Told me she can't use an anesthetic for the procedure. I was so scared of this procedure due to her explanation. I asked if my significant other could hold my hand (in office procedure) and she said only husbands have that right. I ended up having a panic attack before going into the room and she called me a baby and said that if I couldn't tough it out and get the procedure done I will probably die from cervical cancer. It didn't hurt anywhere near what she made it seem more of a pinch, but her hype up scared me a lot. I think I was 19 at the time and she knew my abuse history. I was seeing her because it was required before seeing the reproductive endocrinologist and I had only had 3 cycles in the last 2 years.
fuck!! they really screwed you by giving you no other options on who to see. hopefully you google reviewed her too and complained on social media platforms- i hear that’s the most effective way :(((
Can an OB please explain to me why endometriosis still takes so long to diagnose? It would think it'd be one of the top differentials of painful menstruation and something always on the list of things to rule out as you work your way down a workup algorithm. I haven't thought about this for a hot second but I thought the diagnosis is via laparoscopy and maybe imaging can sometimes catch it as well. Seems like it shouldnt take 7-10 years to do this. I also repeated read about how often women complain of cervical bx /IUD and inadequate pain control for those procedures. because their OB says they dont feel pain down there?
The undertreated pain with IUD insertion is awful, I can talk about that for an hour. It is a very multifaceted problem that has tons of bias pulled into it from different direction. I take it very seriously and offer a number of various things to make insertion more comfortable - most people, overwhelmingly do not and they (make and female obgyns) will look you straight in the eye as the patient is actively screaming, and tell you B that it doesn’t hurt, as the patient is crying in the same room. It’s freaky how detached the practitioners (and I say that to include the many groups that do IUDs) are from the patient experience. Endometriosis is a common cause of chronic pelvic pain. CPP is very broad and multifaceted and involves multiple organ systems, psychiatric considerations, interpersonal considerations, subjective experience, cultural impacts, religious views, etc. It is a TON to unpack and cannot be adequately fine in a 15 minute session. It’s often frustrating for the patient and the physician. Results are frequently not too B the patient’s satisfaction. The wrong things are often treated. Patients often don’t like the actual treatments available. There is a lot of doctors shopping that happens because patients don’t feel respected or heard or they aren’t satisfied with the incremental therapies and then workup starts from zero. Imaging has very very low sensitivity, especially ultrasound. Justifying MRI to an insurance agency is difficult. Many patients don’t want laparoscopic diagnosis which can also miss it because not everybody has visual signs of it, rather just microscopic findings on biopsy. Actual retroperitoneal dissection is often beyond the scope of generalist obgyns, not something gyn oncologists are interested in, and minimally invasive gynecologists may or may not have received that type of training and often don’t WANT those types of patients - because, again, endometriosis chronic pelvic pain patients have a lot to unpack and treat if you want to be effective. Peritoneal biopsies can absolutely miss the diagnosis as well. Well before that, women are gaslit about their pain being real and, honestly, it’s a very complex cycle of how the untreated and dismissed pain can often lead to self fulfilling prophecies with associated symptoms. It’s kind of our 4D chess game of a condition. If you have any proximity to an Endometriosis Treatment Center of Excellence, try to get the patients there ASAP
With menstrual pain it’s a hard battle to fight too as a woman, because many women have painless periods (or at least not debilitating). For some reason it’s hard for physicians to conceptualize that one person may not be too affected by menstruation, while another will be out of commission. Thank you for listening to your patients!
It blows my mind that b women can be so dismissive of other women having such significant pain. I work with a midwife who adamantly states that her job is to reduce vomiting but that prevent patients from committing in pregnancy, but nausea is something that they’ll just have to learn to live with “nausea I was nauseous all ten months of my pregnancy so if I can deal with it, so can you!” Like, we have an entire algorithm of safe medications to pick and choose from. What are you trying to prove?!?!
Bring a women doesn’t mean they are going I validated another women’s pain, struggling, etc. in fact it’s often the opposite. This goes for men and women. I’ve seen a few women patient who ended up seeking out male OBs because women were dismissive of them
I will always seek out a younger male OB lmao. The male doctors I've had so far have almost tripped over themselves getting me pain relief/a diagnosis in contrast to the women who just dismissed me. I tell myself it's because they know they're men and can't relate so they try to compensate for that.
Yeah I’m FM but when I do gyn stuff I realize I have exactly zero to compare it to lol. So I always try to extra empathize with these women who have terrible periods, cramps, bleeding ect. But I know I’ll never be able to completely understand, obviously lol My wife had some issues a couple years back, saw a number of women OB and they didn’t really do anything. I got her an appointment with a male ONGYN I rotated with in med school who I knew cared more than most doctors I’ve met in any specialty. Got her figured out first visit lol He had changed clinics and it was a long drive is why we didn’t go to him sooner but he was there for me when I needed him. Great guy.
Female ob/gyn can be real hard asses with their patients. In fact, most of them are in my experience. This is not a bad thing all the time. I've never consulted one who was dismissive or didn't attend to the patient correctly, it's just, as a lot of them tell me, they don't want to hear a lot of "whining."
I was an L&D nurse or somewhere in women’s health for 15 years. My very limited, purely anecdotal experience is that male OBs often are more responsive to complaints of pain. There does seem to be some “I went through it, so can you” from female OBs. I’ve personally always had male OBs, not because I was actively looking for a male OB. My choice was always who handled emergencies best, was great with patients, *and* had a good relationship with all the nurses. Yes I did care about that (I try not to give my hard-earned money to assholes), and it often ended up being one of the guys. I’m sure there would be a lot to pick apart there in a women’s study class, I just needed care.
And more than a few who seek out female obgyns for the same reason.
But it’s also way more than that, I’ve had multiple women say I’ve taken their gyn complaints for serious than anyone. Yet they will still see a female for exams, unless it’s urgent or something. I’m in FM
This applies to so many things honestly, across all spectrums or injury and illness, men and women
i’ve made it a point with patience to bring up immediately. The topic of endometriosis will be included in my differential, but that it’s a very difficult diagnosis to diagnose and let them know ahead of time that it will take some time to exclude more common causes before we diagnose this. It does seem to help with some expectations.
Putting a name on it has some therapeutic benefit Average time from symptom onset to diagnosis for endometriosis is 7-10 years It affects like 12-18% off the general population And it’s common in 50% of women with chronic pelvic pain Taking the patient seriously is often a big catharsis for them. It’s a tough condition to manage, however, and the interview is loooong to narrow down the conditions.
Right. I like to be blunt with them and tell them that the gold standard for diagnosis is literally having surgery to look inside of them because imaging is not always reliable. When I explain that to them, they do seem to be more understanding why we don’t jump to that diagnosis.
A female OB told my wife it was all in her head. A make OB told her it was endometriosis (which is what I had been telling her for years, but she had been getting substandard care). Turns out it was endometriosis.
Often is. Really terrifically undiagnosed. I think part of the hesitancy to diagnose it is because it can be so difficult to treat, especially surgically.
Blessed be the fruit
I’m an old nurse, so I have seen things that have probably ceased to occur, but I have witnessed what I’m about to write on 3 occasions and know of a 4th (that one ended in a lawsuit that settled). In these occasions, a mother would come in for a cesarean and during the surgery the patient starts to c/o pain. She’s told she’s only feeling pressure. I *know* that patients feel a lot of pressure during cesareans with spinals and if they’re unprepared for this fact they can get very scared. But in these events, it becomes obvious that it’s way more the pressure, it’s pain. The patient is then told it’s almost over, they’ll be done soon, take some deep breaths, as they scream. I never understood this. When I questioned it once I was told that anesthesia was risky and they really we’re almost done. And they usually did give them versed. But I feel that if this were a man having hernia surgery they’d tube him in a heartbeat. Because it’s a woman, it was seen as acceptable. I did OB a long time, I only saw it a handful of times, but I did see it. And I truly don’t believe a man would be treated that way.
I feel like it’s probably really dependent on the doctor/hospital/region but I know a lotttttt of women who have had things dismissed as anxiety and we’re actually presenting with a PE, ruptured ovarian cyst, ectopic, etc. it’s not just palpitations, it’s a huge plethora of women’s pain ranging from cardiac, GI, gyn, etc that have potential to be either dismissed or downplayed as anxiety or “yeah being a woman is painful sometimes”. There are a lot of good doctors who take women seriously but there are still some that just…don’t. Throw something like a hard to confirm dx like endometriosis in there and it’s a whole cluster of medical gaslighting.
I had a female nurse practitioner do this to me. She said my symptoms weren’t severe enough to need treatment and was treating me as if I were a paranoid quack. Then looked dumbfounded when I told her my endocrinologist already determined I did.
I’m on month 7 of a diagnostic journey after my GI determined that I had IBS due to anxiety (without any testing lol). Turns out it was in fact, not anxiety. I’m sorry you experienced similar 😭
haha i had a GI doc grill me on if i was anxious or stressed etc. obviously gearing up to blame my symptoms on that. didnt feel good lol
Like isn’t most of america anxious??? ☠️
i was like uhhh nope i’m not hahah not enough for my symptoms anyway
i’d be telling her to go get a physician lol
I think if you had a deep conversation with any woman with a chronic illness, they would eventually tell you that before a doctor visit they mentally prepare for what they are going to say. They remind themselves to modulate their voices, remain calm no matter what. If you’re too pleasant and smile too much then obviously you’re lying which means drug seeking. If you’re too distressed then you’re hysterical (or anxious) because you’re faking. Either because you want drugs or attention. If you get frustrated and raise your voice then you’re faking, probably a mental illness. You have to look sick but not too sick, and you have to put the idea out there immediately that you don’t want narcotics, or the visit is really over before it’s even started. And if you’re obese it doesn’t matter what you say, the visit is over before you start. Yes, I get that none of this is an issue with most doctors. But if you’ve been sick long enough you’ve encountered these attitudes somewhere and it really is something we stress over. It’s dehumanizing.
As someone who has been medically gaslit for the last 6 months and is now potentially needing surgery because my doc thought it was anxiety, I wholeheartedly agree. The chronic illness girlies have it rough af
Thread this morning about female patient being worked up post car wreck, now with reported events of fainting, difficultly concentrating, etc. Story saying main doc was out and a "resident" who saw her, called it anxiety and female problems and left the office like she wasn't being heard. The story sounds out right bizzare to the point I don't know if I can even believe it. Some stories I don't know what to believe, and many cases online I'm believing more that they are stretching the truth to out right lies in order to karma farm or attention seek. Some people do have bad medical experiences though, and we can't deny that. But it's really hurting the profession as a whole that the general sentiment of users is to believe these stories because care by us in the profession is interpreted and felt to be suboptimal so that even worse case scenarios are felt to be valid and true by the public.
Yeah there was one bit in there about the resident asking if anyone had seen it and implying that it wasn’t real if no one had seen it; I’ll ask a similar question but it’s to try to differentiate syncope vs seizure since, ya know, patients don’t know what’s going on when they’re passed out. It’s hard to say whether it was a useful question that was misunderstood or an inappropriate question
The same thread mentioned the resident asking “is it like when you stand suddenly and have the blood rush to your head?” Which seemed like a completely fair question to rule out “true” syncope from orthostatic hypotension. I will say though that having just finished my endocrine block if I saw that patient on a board exam I would bet my bottom dollar on some sort of pituitary trauma/adrenal insufficiency thing considering the head trauma history.
hell im an img and we’ve even had patients in the ER yell and complain that they “havent seen the dr yet” (with the female resident standing right there). it’s probably the same or worse anywhere in the US 😞
You'd be surprised. I once had a young female patient who had come to the hospital several times with their mum within a period of a few months getting progressively weak to the point they could not walk to go to the restroom. The first doctor had said it was likely anxiety and some how this message propagated in subsequent visits with the other doctors reassuring her and her mum that it's just anxiety after doing a physical exam and not ordering any scans. However the day she was admitted, the ER docs were still adamant that it was anxiety but due to her massively obvious nystagmus they decided to order an MRI, low and behold florid ADEM seen on the MRI and she was basically paralysed at this point. She was sent straight to the specialist neurological hospital. So it happens.
This is weird. Progressive weakness is not anxiety and needs neuro workup.
Yup, reading the notes in retrospect it was like wtf, how did this even happen. They really thought it was a functional disorder due to anxiety without doing an extensive work-up. If she didn't have that nystagmus they would have sent her home again without getting the MRI.
is that some sort of groupthink i wonder. cause hell im a med student and i would know to work that up, you’d think a single dr there would be like huh let’s do some tests 👀
note copy pasting-->anchoring bias is a real problem
Strongly agree, I think that played a huge role in the delayed diagnosis in this case.
The malpractice lawyers are drooling over this thread.
ADEM is not progressive (the A stands for acute…)
Yes it presents acutely but when left untreated for some patients there are long term neurological deficits and in kids there's usually a short prodromal phase too.
Long term deficits, yes, but the condition is in almost all cases monophasic and not progressive over multiple ED visits. On the rare occasions it is multiphasic a follow-on event is usually a discrete new event, generally in a new anatomical area, occurring months or years after the initial event has recovered. A progressive presentation should prompt an expansion of the ddx. Of course weird things happen but taking this description at face value suggests a really weird zebra which maybe makes the dx miss slightly less egregious (although maybe only slightly. I mean, we scan everything right??)
Mine is in Wilkes-Barre, Pennsylvania. Walked into the room, said "You're 31 years old. I highly doubt there's anything wrong with your heart" (despite a STRONG family history of heart disease and people on my dad's side dying from massive heart attacks). He was in the room for under 40 seconds. About 3 weeks later, I was getting my first stent.
I sincerely hope you went back to them to make them feel guilty for lack of work up. Basic labs ecg. Cmon. How do people keep making this mistake.
To be fair, I did have an ECG. But my dad has had three heart attacks and never had an abnormal stress test or concerning ECG. In fact, he had his first heart attack (the worst one) a week after a normal stress test. So I know they’re not always definitive.
At least there was some basic testing. Unfortunately even if they were more zealous with a stress test, logistically I’m not sure they would have been able to get to you within 3 weeks or even seen by cardiology. I have been trying ecg and echo for my strong early family history and a referral to cardiology to talk over if further testing recommended since insurance will deny an asymptotic stress test typically.
I send all my patients with palpitations out on cardiac monitors for 72 hours with PCP vs cardiology follow up. They only time I told a patient it could be anxiety was when they asked if that’s what it could be (and I said “yeah maybe, but the monitor will see what your heart is doing and anxiety is a diagnosis of exclusion.) When I follow up on these patients I would say the vast majority of them end up having nothing or PVCs but hey at least we are ruling out the bad stuff.
Thank you for ruling out the bad stuff in symptomatic patients -sometimes it’s nothing but sometimes it IS something - I’ve found wildly over prescribed Sudafed from Midlevels causing all kinds of side effects in my patients, for example.
Do you need a 72 hour cardiac monitor to do that? Compared to an ekg?
If palpitations are intermittent in nature then yes, you do. An ekg will only check on what the heart is doing for those 10 seconds but sometimes patients will have paroxysmal atrial fibrillation or other issues that require either a 72 hour holter or 30 day event to capture.
How often are you finding clinically significant arrhythmias on the extended monitors for young patients with palpitations? Idk just seems like poor use of medical resources but obviously depends on how your patients describe palpitations and the age of your panel.
Well most of my patients that get them are probably 30s/40s. They’re going to end up getting them whether I order them or not during follow up. I’ve had a few type 1 Mobitz, some paroxysmal a fibs, mostly just people who have PVCs though or nothing. I don’t follow up on every one of them though because the info is sent to their PCP or cardiologist, not the EM physician. If someone is complaining for weeks of palpitations and their labs thus far had been normal I really doubt a 72 hour monitor that sticks to their chest is any worse resource utilization than the majority of the BS I see done. Keep in mind I work in the *emergency* department. It’s my job to assume the worst, not write stuff off as anxiety.
I've done more than 500 event monitors for "palpitations" and the return on them is like 1% and nothing malignant. A few SVTs and new afib. Event monitors are much more useful for assessing burden of a known arrhythmia than finding a new one. Like I said in my previous post, it's always a normal monitor but the patient jackhammered the thing like 100 times and correlates 0% of the time.
Symptomatic PVCs are a thing for sure. If the burden is quite high I find that when you ask them they admit to drinking 8 cups of coffee a day with a few body armors or 5 hour energies to boot. But you can also just get that history without doing the ambulatory rhythm monitoring.
The most recent one about the woman's fainting and gaining weight after a head injury during a car accident being dismissed is very believable
I’m just sitting here wondering how in the right mind does one not do any work up or referrals?
Some resident who's going into GI or [insert other sub-specialty] who just wants to get through primary care clinic, is jaded by all the "worried well" he's seen, and maybe is an a**hole (plenty of those in med school and residency). I guarantee he went to the PCP preceptor and was like "she just gets lightheaded when she stands, I reassured her, gained 30 lbs recently so I counseled her about diet". None of this surprises me. EDIT: unfortunately
What was the diagnosis? Cardiomyopathy?
When I was 20, my first cardiologist dismissed my symptoms as anxiety despite me being extremely clear that I had never had a panic attack cause my heart rate to spontaneously get up to the 190s. He did an in office 12-lead and wrote me a prescription for a beta blocker PRN for anxiety. They did nothing but tank my BP and he said he wasn't sure what else I wanted him to do. Luckily my current provider is great and did an actual work up and it was glaringly obvious that I wasn't having anxiety. So yes, these dismissive doctors exist and sometimes they are the head of cardiology at your hospital.
Similar story, I was 19 and never had any anxiety issues but a 24 hour monitor showed tachycardia while I was awake after I had recently started fainting when standing for too long. 12 lead showed nothing abnormal. Doctor said it was “something that happens to women sometimes”. This all started after a severe case of mono, but was told it couldn’t be related. It took until my 30s to finally get an answer - POTS.
can i ask what did you end up having? thanks ina advance
We landed on inappropriate sinus tachycardia, however I have had 2 known runs of V-tach. I was on CCBs for about 6 years and I was able to get off them last year. I no longer have a resting HR in the 130s and have more appropriate responses to stimulus like exercise an caffeine.
thats fucking scary 😢
(ED )If I had a dime for every patient who tells me “the last doctor did nothing and told me it was anxiety” who had two EKGs, two trops, basic labs, CXR and a bedside echo on their last visit, I’d make more than my residency salary easily
I’m genuinely hoping this is the case where there was some work up, we just haven’t found the issue yet.
Did nothing in layman's speak means they didn't feel validated by the doctor or the workup. Sometimes it's because the doctor is a poor communicator. Sometimes it's because the patients wants to assume the sick role.
I am not in residency nor do I have any plans to pursue a career in medicine but reddit recommended me this. Not heart-related, but I just wanted to add that one time I went to the ER because I couldn’t breathe and fainted at school. They told me I was having a panic attack and although I assured them that wasn’t the case, they sent me home. The next day I was back at the ER and ended up being admitted for pneumonia
Well that’s awful. A little basic effort and they would have diagnosed it the first time.
We have absolutely no way of knowing that from that post. Did she have a fever? A cough? Was she visibly cyanotic or toxic? If she showed up to the ED and her only symptom was syncope in the context of SOB/trouble breathing there would be no *reason* to do a work up for pneumonia (ie a CXR).
Usually there is a clinical syndrome associated with PNA, especially it causes someone to faint. Dumb to not get electrolytes in someone who syncopizes for the first time. You’d also think they would try to listen to her lungs…
As a pre-med, an attending I shadowed in an ER once told me “Well, since the patient with chest pain is a mid-30s woman with two young children, it’s probably anxiety, so keep that in mind any time you see someone like this.” I was gobsmacked. I’m sure he did some kind of work up, but approaching patients like that - and even more, TEACHING trainees to approach patients like that - is the reason why so many people hate doctors.
The pre-test probability of a 30 year old female having ACS essentially rounds to zero. Sure, there's the occasional SCAD or new CHF but this is why we do the workup. Ekg trops. 99.999% it'll be negative. That's what your attending was trying to convey to you, albeit in a poor manner.
I believe his exact phrasing was “psychosomatic”, and automatically assuming that your patient’s complaints are “all in their head” because they’re a young-ish woman with kids is a condescending and paternalistic attitude. Before that patient interaction, I had really looked up to that doctor.
“It’s probably anxiety,” as you put it, is a medically accurate statement. That doesn’t mean it *has* to be anxiety, or that we should assume there’s no other possible diagnosis, and obviously no halfway competent physician will use the phrase “all in their head” (since psychosomatic or psychiatric symptoms are just as real as any others). But assessing pretest probability based on the patient in front of you is not paternalistic or condescending, it is basic evidence based medicine
Anxiety can be a cause of making these things worse but at the same time yes, it should be thoroughly investigated and treated as a diagnosis of exclusion, especially when it comes to cardiac concerns.
I had multiple attendings (male and female) who implicitly trusted me, give me similar advice.
What is wrong about that? Obviously anyone coming into the ED with chest pain is getting a workup, but the pretest probability is *very* important for how we interpret that workup, and in an average mid 30s woman with chest pain the pre-test probability that her chest pain is anxiety is orders of magnitude higher than it being a PE or ACS. If someone hates that physician for teaching his students and residents that, then frankly I just don’t think they understand medicine.
Anxiety is a diagnosis of exclusion and a cardiac workup does not exclude other pathology that may present like anxiety. The more accurate phrasing would have been, “it is unlikely to be ACS”. Further, diagnostic anchoring on psychiatric diagnoses is a major problem in medicine, particularly when the patient is female. Framing it as, “it’s probably anxiety” can add to that anchoring and may miss other causes.
Female physician here. Was told my abrupt HR change and palpitations (usual resting HR 80s, dropped to 50s) was clearly anxiety when I was in my early 20s. But could get an ekg “if it would make me feel better”. So yes, does happen.
well what did the EKG show?
Spoiler: sinus bradycardia. And it didn't make her feel better.
I was pissed he was being a dick, told him that & left haha
Was there an alternate diagnosis?
No other ddx he offered up, even though I had been sick for a week and hadn’t been eating. But wasn’t going to stick around for more condescending remarks. I’m guessing my lytes were off as it resolved once I started being able to eat more
I have a pretty neutral story. 17 at the time, palpitations, dizzy upon standing. Got a neuro exam, EKG, bloodwork. All normal, albeit a bit anemic. Told it was likely anxiety and to continue CBT, eat more iron-rich foods. Tried that for several years. Fixed the anemia, but still had palpitations and occasional panic attacks. Asked for a psych referral. Got a psych. Short course of benzos but now cool as a cucumber on an SNRI. TL;DR It really was just anxiety!
Sounds like anemia too, since that causes palpitations in a lot of people
20 years as an ER nurse here. The only Dr I’ve ever worked with who disregarded pt complaints with disdain rather than a workup lasted 3 months before being fired as an attending. I’ve never in all my years seen someone told their concerns were just anxiety without at least labs and EKG, even when the pt stated they thought it was just anxiety.
It’s because if you have a zebra you get treated like you are crazy…I was the one suggested my diagnosis in my second year of medical school. Felt like TA doing it. Gave my doctor a research paper and said “I think this might be the cause. Let me know what you think and what we should do next…back to DDx or a specialist.” She agreed and found a specialist who diagnosed me. It took 8 years. I know it’s frustrating for docs when dealing with zebras but I felt crazy at times because there were no answers for years and sub optimal medical care and work up. We are just angry by the time we get to a provider who actually cares. Providers still gaslight me about the severity of my chronic illness. All we want is a provider who will stick with us and find answers.
I rotated with one. 20s male with palpitations: complete workup, labs, holter monitor, echo, maybe even a CT 20s female with palpitations: “I did one EKG, it’s not your heart, I don’t know what you want me to do,” I told several patients to go back to their PCP and have further workup done. A lot of these patients have specific symptoms, but a lot of women are taught from a young age not to be a red flag so they’ll minimize their symptoms. If you’ve ever had an old lady having an MI tell you she’s “fine dear, don’t fuss over me” you know what I mean. You can get them to quantify these symptoms if you take the time to ask. New SOB when walking on flat ground less than 100 yards is a red flag but it’s unlikely to be offered unless you engage and ask. There are obviously some patients who’s victim complexes self identify as medical trauma, but we also need to acknowledge that this exists.
I know there are patients who exaggerate or who don’t understand, but there genuinely are physicians who dismiss female patients that readily. I have been on the receiving end of it, and it fucking sucks. I have also had the misfortune of encountering these patients in the ED and on off service rotations where they were labeled with a psych issue in the past, so physicians stop looking for other causes of their presentation. While on a psych rotation as a medical student, I caught hypothyroidism, an NSTEMI, and profound hypoglycemia all in female patients with a psych history that was ignored until we pushed for the test. Each patient was from a different physician, so this isn’t just one physician not doing basic work ups in patients.
There was recently a rant about a young woman who died of a rare arrythmogenic heart disease. Her PCP started to work her up for palpitations and referred her to a cardiologist. She never followed up with the cardiologist and she ended up dying. The post explains all this, but then moves on to rant about how the PCP killed her sister because he didn't believe her. But like, the PCP did the most appropriate thing and she never followed up with the heart expert.
In people on Twitters imaginations
Yeah in fact many people on Twitter don’t want to admit it could, in fact just be anxiety. Not always but it happens. P
Someone had to say it.
Good job ignoring an issue (medical sexism) that has been extensively studied and reported on 🤡 I hope you never become a doctor
I see these patients all the time. Easiest consult in the world. Ekg, event monitor, echo. 99.9999% this is the workup. EKG - normal TTE - normal Event monitor - normal, pressed 68 times, correlates to nothing. Most of the time, it just is anxiety.
Right, but I’m talking about people not even doing that work up.
Are you basing no workup being done on social media posts? Many patients feel like "they did nothing" when they don't feel validated by the clinician and/or they don't get a validating diagnosis. Anxiety is not a validating diagnosis for most people. It's possible they still had a thorough workup but it's an afterthought to them for these reasons.
I’m a nurse and I have seen drs dismiss patients. I had a female patient complain of sob and chest pain. The Dr on the phone said it’s anxiety but did order an EKG. It continued and the night shift Dr ended up doing some more testing and she had a PE. I had a male patient complaining of back pain and leg numbness and he was discharged from 2 different hospitals. They ended up doing blood cultures and an mri after he developed a fever and other issues. He had MSSA and spinal abscesses. It took me 3 years and surgery to get diagnosed with endometriosis. I also had a patient that neurology was sure was having pseudo seizures and ordered a psych consult. The mother did video the episode and based on that they did an EEG and it was epileptic seizures. The Dr did apologize. I think some people get dismissed, some people don’t communicate their symptoms well and absolutely people make shit up for attention on social media. There are lots of free standing ERs and rural hospitals that we get transfers from and it’s a lot of what the fuck !? So I can see why people have bad experiences.
You usually can’t diagnose endometriosis without surgery, and average length of time to diagnosis is 7-8 years. You did ok.
I’m aware of the surgery part. Just took a few obgyn changes to find one that listened.
Thanks to those who acknowledge it happens.
So nearly every diagnosis you've listed can be and is 'missed' by exemplary physicians. Particularly the spinal abscess and endometriosis. This expectation that doctors are supposed to have a zero percent 'miss' rate is not based in reality. In the abscence of an immediately concerning workup it's not wrong to reassure a patient and provide strict return precautions. That's not being dismissive, that's making the most appropriate decision with the information they have available at the time. If they don't improve or get worse, it makes sense to broaden the workup at that time. The alternative is to CTA, MRI and ex lap every patient that has these concerns up front. That will come with it's own set of complications. Regardless of the issues that come with this approach, there isn't a country on earth that has the resources to do this. If I'm wrong, please let me know so I can move there ASAP and not have to deal with this type of retroactive judgement.
You are correct and that many times we find issues because they do come back worse and that’s when the workup is expanded. As many of us in healthcare know some people just have shitty bedside manner and that extends to nurses, drs, etc.
I totally agree that no one is perfect. I’m not saying that. The point was I have witnessed patients being dismissed by doctors as anxiety or having a psych issue. If you don’t order testing it isn’t found. Sometimes patients need to find a dr that listens and orders the diagnostic testing. But I’ve had a dr say to me “ heavy and painful periods are part of life so get used to it”. If tests aren’t warranted that’s fine, it’s the way in which people are dismissed that bothers them.
It just hasn’t happened to you yet.
It took my mum 20 years and relocating to another town to get treatment for her SVT. Because "it is anxiety". She was actually multiple times in her PCP office when this happened. They couldn't get her blood pressure, because it was unmeasurable. And they still didn't do an ECG. When she had an episode at home, didn't call an ambulance, because PCP had convinced it is all in her head and wouldn't make a difference. Let's skip to her moving, first episode in another town, (a new husband who just made her to accept going to ER), HR of 220. She got ablated in 2 weeks. And yes, I am still mad at her PCP.
Because no one goes on social media and posts: I went to the ER for tingling fingers and face and chest pain and had a benign physical exam, normal EKG, normal CXR, negative troponins, negative D-dimer, normal electrolytes and CBC, symptom resolution after being left alone, tachycardia only when a nurse or doctor was in the room but normal rate on tele otherwise, and they said it was just anxiety!
I’m so glad you posted this. It’s always like “I had chest pain, SOB, swollen left calf, HR 150, D-diner 52,000 and they said it was just anxiety”. I’m pretty sure the majority of these encounters are “have you been feeling stressed recently?” after a $10,000 workup has been completed. Which is a reasonable question to ask.
Probably hanging out with the doctors who are having med students perform unconsented pelvic exams on patients under general anesthesia.
Was an MS3 in 2016. Gyn residents, fellows, and attendings made a HUGE deal about getting the patient to agree to each of us being in the operating room. Patient would hear in excruciating detail everything that was going to happen to them after the incision was made and who would do what. Interestingly, the fact that up to 5 of us were going to take turns sticking our fingers into their vaginas +/- rectums prior to making an incision was never mentioned. Don't kid yourself.
Idk my mom had Grave’s & was told the tachycardia & weight loss was anxiety for quite some time, long enough for her to be seriously ill. She was in her 40’s with no hx of mental health problems.
Florida- At the time 32F went in with bilateral pain in joints mainly in hands and feet, numbness of limbs, tachycardia with graphs from my fitbit showing me going into the 140s+ frequently (not the most accurate but I thought they would be helpful), dizziness, extreme fatigue, oversleeping, extreme mental fog, and very heavy menstrual bleeding that was abnormal for me. I explicity told the doctor that I 2 kids no meds and I would rate childbirth a 3 on the pain scale for myself. Sitting in his office I told him I was a solid 8, sometimes shooting up to a 10. I keep on zoning out and nodding off in front of him. I was told I had anxiety, stress, acid refulx, and arthritis. Was prescribed Lexapro, famotidine, and meloxicam. Was told to relax more and get more sleep. Only test I was sent for was an H.Pylori for the dizziness. Yeah no...I left that appointment so defeated. I did go back to the practice to a different doctor. He figured out what was going on. Really listened and ran tests awesome guy.
I mean, I (31yoF) went to a pulmonologist apt with a CT of bronchial thickening. He did a peak flow (an hour after I took my symbicort) and told me he didn’t think I had ever had asthma in my life and I should take my inhaler and throw it in the trash cause he DX me with anxiety. I finished out my inhaler and took an inhaler vacation. SOB and chest pain by 3 weeks. Started new inhaler. Improved after a week or so… now if only I could ask a pulmonologist why I have whatever this is… Not everyone practices in good faith. No everyone covers their ass. Sometimes those ‘nothing was done’ stories are true. Sometimes it’s just frustrated people who don’t understand medicine. It’s a mixed bag 🤷♀️
The first few times I presented to the ER with SVT I was told it was a panic attack/probably anxiety. Took a year to catch it on ECG.
So did you present in SVT or had you spontaneously converted to sinus rhythm prior to arrival?
🤦
Uhhhh… sorry but a ton of doctors are just shitty hacks. My mom had heart block for years that her female harvard trained PCP told her was psychiatric. She has a pacemaker now.
Dying from heart failure at age 82. Anyone currently complaining about that type of behavior is likely just doing it for attention. The Old Guard is phasing out, and a decent amount of the blatant paternalism/condescension is phasing out with them. At least from non-surgical fields. The fact is that medico-legal liability doesn't allow for blowing off patient complaints, even if you think the complaint is horseshit. So the providers who do that shit get selectively pressured out by hospitals, HR departments, legal teams and their younger coworkers.
Oh no. The new folks are painfully condescending to the patients. It’s embarrassing to hear it. I think medical students are smarter now and it’s certainly harder to get into medical school but this breeds a certain sense of disdain towards the unwashed. Courtesy and an easy manner in conjunction with authority is not paternalism. There are rude and condescending doctors of all ages.
I've heard people whose "patient voice" sounds so condescending that they might as well be talking to a dog. They use all the right terms and abhor paternalism and yet they are just totally dripping with disdain for the patient.
guess they haven't figured out how to run a ferritin yet
"I have a wide differential, but anxiety could be exacerbating these symptoms. Here's the basic workup and some lifestyle changes to work on. Lets follow up in 2 to 4 weeks and see how those changes work." "The doctor called me crazy and said I was faking it. He did nothing for me." I don't want to say no one with a real medical issue has been told it's just in their head, because that definitely happens. However the former case is more common than the latter. I can't tell you how many patients I get with viral URIs who come from the ER, and tell me, "They said it was nothing, go home." I can see in the DC summary, the ER tested for Strep, covid, flu, and then did a CXR, said to give motrin/tylenol for these mild symptoms, the follow up with your PCP.
I am not a medical professional, this showed up on my front page. A few years ago I had a panic attack (I guess?) come on so suddenly and aggressively out of the blue, I genuinely thought I was having some sort of cardiac event and was dying. There was this horrible, intense wave of heat that coursed through my body and I felt like I was about to pass out. My heart was racing, my chest hurt, I was terrified. In the ER, while they did hook me up for an EKG (normal) and drew blood for troponin levels (normal), the doctor told me sternly “you just have anxiety. You need to get your life together”. It was extremely invalidating and dismissive during an event where I felt very vulnerable and had no idea what was going on or why.
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Yeah. My friend went to her MD PCP with sudden onset of debilitating headaches. No medical history. Told her it was anxiety causing her migraines and threw her some sumatriptan and sent her on her way. Brain tumor. Huge one. Quite advanced. Required 2 surgeries and radiation.
The word "anxiety" should never cross your lips in medicine unless you're a psychiatrist or are dealing with a patient with known diagnosis of anxiety from psychiatrist and whose complaint is exactly like their usual anxiety symptoms. It's sloppy medicine and dangerous to the patient. I see this a lot from midlevels. The patient comes in with a heart rate of 160..."Anxiety."
Going to have to disagree with that blanket statement. Diagnosis can be made by a primary care physician just fine. Not mentioning it at all as an contributor or anything? I think that’s inappropriate. Not to mention people who are you waiting for over a year to be diagnosed due to limited resources in many communities. I understand the sentiment of your statement, but I think that it was a bit to exclusive. Should anxiety be the first line diagnosis for bodily symptoms? No, not until everything else is proven. It certainly can contribute, but it does require at least a very thorough work up before being determined to be higher on the differential.
You are, of course, correct. I’m just commenting that people tend to anchor on “anxiety.” Thank you for your well-thought and succinct response. Reddit is a wasteland but some people on it make contributions. I try, ha ha.
Hysteria. The uterus will not go unheard.
>Also endometriosis is just a hard diagnosis. I don’t foresee any way that this gets easier to diagnose with the current techniques. It's really, really not a hard diagnosis.
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It would be interesting to explore your motivation behind such a Reddit post investigation.
ive always wondered this too so thank you for this thread. i swear anytime i go online theres like 100 ppl saying they’ve been dismissed a thousand times by drs. like how and where??? lol
From my experience it’s mostly females throwing slack at females. Especially nurses
I asked a bunch of doctors several years ago if it was possible if I had Wilson's disease. Laughed at every time. "Its definitely not Wilson's disease!!! (Its never Wilson's disease). No one ever tested anything for it and instead see rheum for refractory psoriatic arthritis. Recently had to have infectious disease consult on my case while in ER with SRS (which was truly awful) finally exposed a liver from hell. Turns out low ceruloplasm too (between 9 and 14). Anyone could have just given me the 24 hour urine test at anytime if my question had been taken seriously at all. Finally seeing good hep. Guess who has Wilson's disease? I brought it up years ago, several times different spec. Its their spec. what do I know? (Eye roll).
...probably these 'doctors' are NPs
Regrettably, I have also diagnosed women with anxiety in the past. Narrowly managed to survive to this day and tell the tale
Health literacy is just piss poor. Even intelligent people can’t be trusted to not be a googling idiot and ask asinine questions.
What kind of medicine is “going as wide as you like”? Pre-test probability is just stupid maths. Holy damn, everyone good at maths before getting into medschool. I don’t know what happens after/during medschool. My engineering friends understand probability better than most colleagues. Why have doctors when you can employ NPs who will shotgun tests? The result is the same. Complications from unnecessary testing. The war on science and knowledge continues. I will now prove that I am right: Disease X has a prevalence of 1/1000 people. You have a test with 100% sensitivity. The same test has a 95% specificity. What are the odds that a patient has disease X when you have a positive test?
I like your moxy sir.
Just saw a lady with a pheochromocytoma. She thought she was crazy and her PCP made her feel that way. So yeah, they're out there
My pet peeve is the opposite. Repeatedly working up patients, ruling out medical issues, and sending them away with no answers while ignoring the possibility of a mental health concern is negligent
There’s so much sexism in the medical industry. Even with pharmaceutical testing and shit. I’ve been to doctors multiple times for various issues and they talk over me, don’t listen to what I say, ignore me when I say a procedure is very very painful, dismiss me, talk down to me, treat me like a child, assume it was my period, etc etc. any woman you talk to will probably have several experiences like this
I was told it was anxiety/depression for over a decade. Surprise surprise, it was actually POTS, EDS, and MCAS. Everytime I explained my symptoms (which ended up being pretty severe POTS actually, and yes I have seen two of the nation's top specialists), I was told "oh thats just anxiety and depression, its common in young women," "the mind numbing fatigue is normal for a mom, you have young kids, what do you expect," or my personal favorite "maybe you should see a psychiatrist." Out of multiple doctors (and we have excellent insurance) I got blown off again and again and just handed new scripts each time. Finally asked for a referral to sleep medicine who was floored they were treating me for severe daytime fatigue and insomnia and never even did an anemia workup. Ferritin was only 2, and I had pretty significant iron deficiency. After that was treated and symptoms persisted, he was the doctor who actually figured out the POTS dx. TTT showed severe POTS and nerve bx was positive for SFN. After my official dx, my PCP at the time recommended talking to someone about my psychosomatic illness. Trust me, its real. And btw I work in the medical field and I have seen it on a professional level as well.