Tuesday, 3 February 2009

Occupational Health - Second opinions or Glimpses of the Obvious

Last week I saw three patients in rapid succession whose NHS doctors had made the wrong diagnosis, missed the diagnosis and ignored the diagnosis.

Occupational Health is about getting the patient back to work, and if that involves sending the patient back to their NHS doctors, I do what it takes.

Person 1 injured his hip four months ago and has been off work for four months.
He complained to me of hip pain, he complained to his physiotherapist of hip pain, he complained to his General Practitioner of hip pain, he complained to his Orthopaedic consultant of hip pain. As far as I could tell, I was the first person to examine his hip since his initial visit to Accident and Emergency, where he was Xrayed

He gave a story of a "dislocated hip". This is unlikely - First, dislocating a hip takes a massive amount of force (FTR - hip replacements dislocate easily). Second, it takes a full general anaesthetic and a lot of effort to put them back.

However! - he did this during a Rugby game - and the "other buggers were big" - and he was immediately treated by an experienced physiotherapist who manipulated his hip and it then felt a lot better. But he still couldn't walk. He has not walked properly since.

His back did not show much wrong when I examined it, but when I examined his hip by feeling in his groin, which is where the hip joint can be felt - he hit the roof with pain. And this guy is a tough cookie. I have sent him back to his GP with a letter, and not back to work.

Person 2 has had funny turns for the last four years. He has extensive investigations for heart disease even to the point of having a stent put in. However his "funny turns" persist and to his mind he is worse than he was when he first went to see his doctor.

He is short of breath, he can't comfortably lie flat, he has episodes largely at night of feeling strange, even as though he has been stabbed in the chest and is about to die. The last doctor he saw almost got the diagnosis. But they sent him for a scan, and four days later the scan was normal. He also goes on long coach trips.

This is a classic story of recurrent pulmonary emboli - and the cardiologist put in a stent because he is fat geezer with slightly narrowed arteries to his heart.
I put him off work and wrote a note to his doctor, asking him to arrange for him to be investigated for pulmonary emboli and raised blood pressure in his lungs.

Person 3 also had dizzy spells, but of a different type perhaps more related to long term night shifts. But a twenty four hour ECG has shown his pulse slowing to 33 beats per minute.

He was told by his consultant that this was normal for a fit person. He is over 50 and even Rebecca Adlington's pulse rate never gets that low. He needs a pacemaker.

The morale of these stories, is that the diagnosis comes from understanding the patient. All three had been seen by consultants in major teaching hospitals. A consultant appointment was once a gold standard.

The difference between consultants and an occupational health physician is not so much one of skill but of time. All three diagnoses were in the history. "Investigations" can be wrong, Person 2's scan was done too late and in any case would not show up small clots on the lung (pulmonary emboli). They look at the wrong part - Person 1's MRI scan looked at his back not his hip. "Investigations" can be right and be ignored, as was the case with Person 3.

I would like to think that even ten or twelve years ago, I would not have found so many diagnoses. Roughly one in ten of the people I see, have the wrong diagnosis. Nothing, even in this high tech world beats a good history and examination. People matter, and cannot not be fobbed off with a few high tech tests, when they need a proper medical opinion.

Once upon a time, I thought tests were better and more reliable than doctors. Whether a Masserati is a better car than a Ford depends on more than the technology under the bonnet. If a blind person is driving the Masserati, you are safer in the Ford driven by someone who first finds out where you want to go.

Copyright Dr Liz Miller, Well and Working Ltd



  1. how true that is

    I saw someone with a problem that had been mentioned in the GP's referral letter 2 years ago

    They werent being treated for it

    They had the sign of hertoghe and it was a barn door diagnosis

    Why waste my time?

  2. There is something wrong with the medical profession - deeply wrong! and thanks Henry for your comment