By David Jolley
We were presented with a series of beautiful brain scans – showing no pathology in a middle aged woman who had complained of failing memory – substantiated in the practice of everyday life by her husband.
Physically apparently well. No obvious emotional or social difficulties.
A mystery
There is an urgency to achieve a diagnosis. Over and again we read of individuals and families complaining that it took years – too long – to get the right diagnosis and that they suffered as a consequence.
More recently we are hearing of people who find themselves perfectly OK ten years or more after being told they have Alzheimer’s disease. Some will take clinicians to court for misdiagnosis.
I am reminded of Eliot Slater’s famous paper published 1965 in which he followed up 85 out of 112 patients diagnosed with ‘hysteria’ at the National Hospital for Nervous Diseases, Queen Square, London in the 1950s www.bmj.com/content/bmj/1/5447/1395.full.pdf
These people were quite young – average age for men being 42. For women 37. Yet during the follow up of 9 years 12 had died, 30 had become disabled and only 19 were symptom free. Of course we have much more powerful techniques to investigate in 2021 – but the point remains that even in-depth investigation at one time has its limitations. History for multiple sources, physical examination as well as investigations represent the best of good practice – but they must be supported then by careful follow up. Things may get better. They may get worse – but for sure the only safe model is for patient and clinician to remain in touch – sensitive to the emergence of new symptoms and to clues about underlying processes as they emerge.
We cannot always get things right first time – but if we travel together and share in the learning – we will get it right in the long run – and be forgiven for uncertainties on the way. The fashion for services, which are fragmented between individuals and agencies is wrongheaded and vulnerable to errors, which are not quickly realised and corrected.