Diagnosis: Do It Well Or Not At All

Medical Author: Jay W. Marks, MD

During my medical school training, I remember being counseled by one of my instructors; "In the practice of medicine, it doesn't matter what you do, it's how you do it." I thought she was being facetious, and I didn't give her advice much thought. Now, after years of practice, I understand what she was saying, and the truth of what she said was reinforced recently.

I was asked by a physician to see a patient in consultation who had been having episodic abdominal pain every few weeks for at least five years. She had undergone a hysterectomy (removal of the uterus) followed by radiation therapy for cancer of the uterus. The pain began a few months after the radiation. All types of testing had been done, including x-rays of the small intestine, to diagnose the cause of the pain but no cause had been identified. Almost in desperation, she underwent abdominal surgery to remove scar tissue (adhesions) between several loops of the intestines. (Adhesions often cause abdominal pain.) Even surgery was to no avail, and within two weeks of the surgery she was having pain again. I was seeing her two years after this latter surgery.

I took a careful history and examined her. She was a very good observer and could describe the progression of a typical episode of pain in detail. To me, it sounded like she was having intermittent obstruction of the small intestine. Taking x-rays of the small intestine after drinking barium is one of the best ways of diagnosing intestinal obstruction, and, indeed, she had such an x-ray prior to her most recent surgery. The x-ray was sent to me, and I reviewed it. There was nothing abnormal about it. I asked her if the x-ray was taken at a time when she was having an episode of pain. It was not.