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“… for the secret of the care of the patient is in caring for the patient.”— FWP
Annie was 30 years old when she came to me for treatment of systemic lupus erythematosus (SLE). At age 15, she had gone to her primary care physician with a red, bumpy, sometimes itchy rash on her face and arms. The rash would appear after prolonged exposure to the sun and would slowly fade in a few days. She had had no other complaints. Her doctor had ordered an antinuclear antibody (ANA) test, and when it came back positive, he told her that she probably had an early connective-tissue disease, most likely SLE.
The thought of having SLE had devastated her. A close friend had died of SLE, and Annie feared that she might suffer the same fate. So she refused to get married, thinking that she would be a burden to her husband and children. Nevertheless, she remained physically well for the next 15 years and took no medications. Moreover, she reported not ever having joint pain, Raynaud's phenomenon, hair loss, dryness of the eyes or mouth, oral ulcers, pleurisy, or unexplained gastrointestinal or genitourinary symptoms.
Because of a promising job offer, she had moved to my area, and she was referred to me for follow-up care. Review of her accompanying medical records showed that, over the years, her complete blood counts, serum creatinine values, liver function tests, urinalyses, and serum complement levels had been normal; her ANA titers had ranged from 1/320 to 1/640 in a homogeneous or speckled pattern; and antibodies to DNA, ribonucleoprotein, and hepatitis virus had been absent. Biopsy of a skin lesion had shown “spongiotic dermatitis without evidence of SLE.”
These important details from her medical history, together with my normal findings from her physical examination, enabled me to reach a confident conclusion. “Annie,” I said, “there is no evidence that you have lupus or any other chronic disease. Your skin eruption is heat-sensitive, and you should wear protective clothing when you are in the sun.” Startled for a moment, Annie then bolted from her chair, gave me a big hug, and with tears in her eyes, joyfully said, “Thank you, Doctor, for giving me my life back.”
Annie's story illustrates several key concepts that have guided my practice of medicine. Chief among these is the importance of taking a meticulous medical history. In Annie's case, there was absolutely no evidence of red-flag symptoms pointing to a serious diagnosis. Further, her laboratory results needed to be taken in the context of her history and physical findings. Ordinarily, the laboratory can help confirm or refute a diagnosis, but it rarely makes the diagnosis. A positive ANA test in a young and otherwise healthy woman, for example, is more likely to be an incidental finding or an accompaniment of a benign condition than a marker of a serious disease.
Fortunately, Annie responded positively to my having taken away the diagnosis that she had carried for 15 years. I have learned, however, that changing a long-standing diagnosis can also cause a patient to become angry and resentful. As Peabody himself emphasized, physicians who make wrong diagnoses and ill-considered statements are responsible for many wrecked lives. He also warned that it is much easier to make a wrong diagnosis than it is to unmake it.
In my practice of rheumatology for the past 35 years, I have derived immense satisfaction from establishing the right diagnosis and providing appropriate therapy for my patients. In Annie's case, however, it was taking away her diagnosis that afforded me even more satisfaction.