Experts and biases

I wrote a while back about my view of doctors as experts on the health of the body who I trust to investigate it and advise me on it. I’ve been thinking about this lately because I’ve been seeing some doctors about my ankle. I’ve seen a podiatrist after each of my acute injuries, followed by a physical therapist. I quite trust the podiatrist I’ve seen to diagnose acute injuries; he was the one who identified that my original sprain wasn’t a simple ATFL sprain but rather of multiple ligaments and a tendon. But he hasn’t had any ideas as to why I had persistent pain.

In the spring I saw a new podiatrist and another physical therapist. Just lately I’ve seen two orthopods (both primarily surgeons, I believe). I’ve had three x-rays and two MRIs. So I’ve been through a lot of physical exams and imaging findings and discussions about my injuries. One of the things that I’ve been quite disappointed by in the MDs is the lack of interest in the exact nature and pattern of my symptoms. They all ask questions about the history, but they don’t seem interested in precise answers, even though I’ve written up a detailed timeline and can describe the location and quality of the symptoms clearly. They do more or less a standard exam for gross tissue injury in the ankle, look at my films, and declare that there seems to be nothing awry and they aren’t sure why I’m in such pain.

At the last doctor I finally got a reasonable enough explanation of what a diagnostic injection to my ankle joint would do and decided I’d like to have it done. They basically shoot anesthetic into the joint, and then you do things that should hurt. If it helps, the joint may have a problem. If it doesn’t, then it’s probably a soft tissue problem. So they did, and I did, and my foot still hurt, but there was something interestingly different about the quality of the pain. A tenderness that I’m accustomed to was less prominent; the pain was less focused, and less intense, probably about 3/4 as intense.

After the injection I was thinking about what exactly hurt less, and why it might hurt less. I remembered something that my most recent physical therapist mentioned a few times: the cuboid bone. He said that mine was in the wrong place, and he was trying to put it back. The cuboid bone is below the fourth and fifth metatarsals, and abuts the calcaneus (heel bone). So it’s near the main (talar) ankle joint, but not exactly in it. Hmmm. It sounds like something that might have been remitted by a local anesthetic in the joint, but not entirely eliminated by it. I started searching for problems with the cuboid, and sure enough, there’s a thing called cuboid syndrome that almost exactly matches my symptoms.

Holy cripes, people. I might have a thing that there’s a name for! And specific treatment for. And yet, I’ve had it on and off for literally three years, and no one except my PT has ever said the word cuboid to me! I want to call all the doctors I’ve seen and say “Why didn’t you mention this thing?!?!” I can see from the literature that cuboid syndrome is mostly a diagnosis of elimination and it’s not a very well-defined phenomenon, but fuck. What else were we doing with the X-rays and MRIs besides eliminating things and what were we doing with office visits besides discussing my symptoms and their possible explanations?

Technically I haven’t heard back from the newest doctor yet since I reported my results, so I probably should give him a chance to actually come up with this idea. But regardless of whether he does, what I’ve been thinking about is the way that even as a expert in an area, it’s so easy to stay inside the little box of your well-worn standard tests, and not know about, or not think about, other possibilities. I see this happen not infrequently at work, and I know that I also occasionally fall into it myself. The first thought on seeing a thing that is anomalous and isn’t explained by common problems is “That can’t really be possible.”

And a lot of times, especially in tech support, it’s true. It is more likely that someone messed up something subtle in their firewall configuration than that our system (which is otherwise functioning normally) is not functioning correctly just for them. It is more common that you didn’t attach that custom information to your data, or didn’t do so correctly, than that it’s not being processed because of a bug. But it’s also intensely frustrating to be on the other end and deeply know that you must somehow have the information that is needed and just can’t convey it to the person on the other end. It’s a reminder to all experts to be humble, curious, and open; to search for details in the data and entertain new ideas about what might explain them. If you listen carefully, you might get just the information you need to help someone.

2 thoughts on “Experts and biases

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      December 27, 2015 at 12:22pm

      Hey, that first one is an awesome story. I’m glad it turned out she didn’t have carotid dissection (I checked out the update episode). I might check out CrowdMed eventually, cause after spraining my knees I’m starting to wonder if I have a systemic issue. Gotta try a few more doctors first though.

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