The difference is actually finding the root cause or just diagnosing what’s essentially a symptom as if it’s unexplained or isolated (idiopathic, I think is the term?).

My mother was diagnosed with anemia, and received many recommendations ranging from not drinking tea to getting a hysterectomy (which was done, in her mid 40s). It turned out she wasn’t absorbing iron due to Celiac disease. Treating the anemia as if it was an isolated condition wasn’t helpful at all since she needed to address the root cause, Celiac.

“Anemia” isn’t really a diagnosis.

Your mother had a microcytic anemia (a broad class based on lab results), of which there are several types including iron deficiency anemia.

Next, there are multiple causes of iron deficiency anemia of which celiac disease is one of them.

You would never diagnose a patient with “anemia” and stop there. Further work up for the etiology is mandatory and endoscopy is commonly performed.

There is no such thing in modern medicine as “just treating anemia” unless you know the cause and the only treatment is transfusions.

I would imagine that more details were available, but I’m recounting some thing that happened to someone else 30 years ago when I was a teenager. So I’m not really clear on the precise details. All I know is that they said she was low on iron and anemic, and the suggestions were to not drink tea and they gave her a hysterectomy. As noted, they failed to discern the actual cause at that time. She was diagnosed with celiac about 10 years later.

This is a good learning/discussion point: The post common cause of iron deficiency anemia in menstruating females is menorrhagia. Celiac disease is often an acquired disease in later adult hood.

This is not to comment or challenge directly your case but knowing the two above facts it is not uncommon (in fact I have personally seen this in practice) where your above outline is perfectly reasonable.

A woman may have multiple reasons or a sequence of reasons for IDA, developing celiac later in adulthood - it’s totally possible they had chronic blood loss anemia before that.

> You would never diagnose a patient with “anemia” and stop there.

I kind of doubt that. In my experience, the treatment for chronic heartburn is to throw meds at it to stop the symptoms. After an upper endoscopy, no attempt at root cause was ever made.

As much as you doubt that based on your anecdotal experience (addressed below), I’ve respectfully spent the past 9 years practicing medicine in 16 different hospitals across three countries and feel I am in a more appropriate position to comment on the medical standard of care.

I can say with absolute confidence at none of the places I’ve worked at would a doctor leave a patient with a diagnosis of anemia as this is malpractice. Are there physicians in some hospitals who practice negligently?

Sure, but there are also pilots who show up drunk to work and engineers who are negligent. That doesn’t mean the entire profession has a “problem”.

Anemia is not heartburn. Anemia can be life threatening.

As an analogy for the tech world. Anemia is a server crash. Heartburn is a warning in the server logs.

You may decide the warning is not worth fixing / may result in new bugs (aka complication).

When a server crashes step 1 is to get it back online (transfuse to a safe hemoglobin target).

Step 2 is find out why the server crashed (why is this patient anemic, which is a sign/symptom and not a diagnosis).

Just as a computer engineer would never say “I’m not sure why but let’s just keep restarting every time it crashes”, a doctor would not say “I’m not sure why you’re anemic” unless there was an extensive negative workup and the patient normalized therefore no longer requiring treatment.

There is no situation where a physician just keeps transfusing an anemic patient without figuring out why. This is not only expensive, but transfusions carry risks and with repeated transfusions some risks increase. This is not a medically accepted management plan anywhere and the hospital / blood bank would quickly intervene if a non-hematologist was serially transfusing a patient as this is outside their scope.

In your example:

Your negative endoscopy excluded H. pylori, gastric malignancy, peptic ulcer disease, and a hiatal hernia. Those are all of the easily treatable and life threatening conditions we should not miss.

Your next options for investigation would be a 24 hour pH study with consideration for fundoplication. This is a major surgery with risks and complications that are believed to be worse than PPI therapy.

Patients who fail PPI, are unable to be weaned, or have contraindications are the ideal candidates for such an invasive procedure. You don’t want to send every heartburn patient to fundoplication, we used to do that and made a lot of people worse.

I feel that patients are qualified to comment on medical standards of care, also.

I am sure that you’re a good doctor, but to answer your question, yes, there are many doctors who operate negligently, to some extent. I had a long experience at one of the major hospitals in the US following drastic weight loss and months of pain. A major hospital did various tests, and ended up telling me I had “health anxiety”. It turned out that I was actually developing LADA, a form of type 1 diabetes. Since I had already been diagnosed with celiac and was having primarily digestive symptoms, the tests they did focused on the digestive tract and they never investigated other causes. I had to finally go into diabetic ketoacidosis before anyone figured it out.

Unfortunately you are confusing “medical standard of care” with the “standards of medical care”.

“The most common legal definition of standard of care is how similarly qualified practitioners would have managed the patient’s care under the same or similar circumstances. This is not simply what the majority of practitioners would have done.”

Source: https://biotech.law.lsu.edu/map/StandardofCare.html

As you can see, patients are not qualified to comment on the medical standard of care and unfortunately how you “feel” isn’t a consideration in the decision as this is established in case law.

To your larger point, if you are dealing with a negligent doctor the place to address it is at a medical licensing board. With a single paragraph complaint they will gut a doctor for diagnosing anyone with “anemia”.

Instead of spreading partially misremembered stories online and spreading vitriol I suggest you use the many, free channels available for recourse if you feel your doctors actions constitute malpractice.

I appreciate these things can all sound similar and be confusing. Perhaps best to leave to the professionals dedicating 10+ years to learning the trade.

How would you have done your diagnostic workup differently than what was done - specifically?

What was the negligence what was the diagnostic smoking gun that was missed?

> I feel that patients are qualified to comment on medical standards of care, also.

Patients like doctors is a huge group that should not be generalized - but health and healthcare literacy is pretty bad so by and large, no, patients can comment on standards of care but they aren’t qualified to do so.

> If your wife had hemoglobin that low, then she was correctly diagnosed with anemia.

That seems like a somewhat myopic perspective.

Saying this patient was "correctly diagnosed with anemia" would be like diagnosing a cancer patient currently undergoing chemotherapy with male pattern baldness.

A more accurate and helpful diagnosis would probably be something like "Babesiosis"——anemia caused by ticks infected with a microbe that destroys red blood cells especially considering the multiple cofactors at play. Or whatever it was that specifically caused the anemia; the parent comment didn't say.

Dude, I'm just addressing this: "So things that can look like anemia can be other things! Case in point, my wife was misdiagnosed for months with Anemia."

Which is a bit of a confused statement.

> Saying this patient was "correctly diagnosed with anemia" would be like diagnosing a cancer patient currently undergoing chemotherapy with male pattern baldness.

No, that's a pretty shit analogy and completely wrong. First, because chemotherapy doesn't cause "male pattern baldness" - the mechanisms aren't the same. So that's just wrong - while someone with a hemoglobin of 4 has anemia, whatever the underlying cause may be - it isn't a look alike - it is.

Second, diagnosing Alopecia (secondary to chemotherapy) is a perfectly reasonable diagnosis. Because it is something that doctors do manage with specific things separately from the chemotherapy and other cancer treatment, eg wigs, scalp cooling.

People can have more than one relevant diagnosis that they are treated for and are interrelated. For instance, if someone has anemia that is due to something like a GI bleed, they have both a GI bleed and anemia. If their hemoglobin is less than 7 you will likely treat that anemia with a blood transfusion independent of what you're doing to manage the GI bleed. GI bleed, iron deficiency, malabsorption, microcytic anemia are all diagnoses - they may be all interrelated.

> A more accurate and helpful diagnosis would probably be something like "Babesiosis"--anemia caused by ticks

But babesiosis is not anemia. It often occurs with it, but the diagnostic criteria for babesiosis is blood smear or PCR. If someone has a smear positive for babesia then they have babesiosis regardless of their Hgb/Hct.

And notably they listed a bunch of tick borne illnesses listed, babesiosis was not among them.

> I’m sure you’re here to rub your reflex hammer in our ignorant little pig faces.

I do realize there are a lot of crappy doctors out there, but about the person putting a reflex hammer in your face -- are you sure that was an actual doctor?

To your other point, while I often realize the futility of responding to the direct commenter, this is a public forum so maybe others can get some information or entertainment, whatever might be.

As a physician I am in complete agreement with danachow’s statements.

A hemoglobin of 4 must be corrected irrespective of the underlying etiology.

Furthermore, I am also in complete agreement that such a patient without obvious source for anemia requires a hematology consultation. That may be the only error that happened here.

I would greatly welcome your rationale as to how we can safely discharge a symptomatic patient with a Hgb of 4 as this directly contradicts all of my medical training. In fact, I would lose my license if I ever did that.

If you happen to know information about anemia I do not, please provide your rationale.

I've gone into the doctor with a BP of 160/90 and a headache that had been with me for 3 days.

After asking some scary questions and ruling out that I wasn't going to die then and there, I was sent on my way and told good luck.

I figured out myself that the problem was a potassium deficiency. I hadn't eaten any leafy greens in a week or two (lots of veggies, just none that had significant levels of potassium) and I don't normally eat any processed food.

A couple handfuls of baby spinach later and my headache was gone.

A lack of effort in diagnosis is the norm, not the exception. I have plenty of other stories! As does damn nearly every one else.

Computer techs don't bother diagnosing PC problems and just prescribe a reboot. Many Doctors seem to have the same attitude, but for the patient things are a bit more personal.

I’m sorry but I’m not sure how this comment relates to mine which asks for clarification regarding the deleted poster’s treatment algorithm for anemia.

I will however address the gaping flaw in your story. Depending on which doctor you see, their job isn’t necessarily to diagnose you.

When I used to work in the ED as a resident our job was to make sure no one died, workup for non-life threatening headache was not our job and was for the outpatient physicians. Depending on the type of clinician and context this may not have been their job.

If this was an urgent care/ER visit, I would be shocked if they did not draw serum lytes and other basic labs. If they did, then you would have known if you had hypokalemia

Furthermore, your timeline does not prove causality. Most headaches go away on their own and this may have been simply what happened to you.

Lastly, I don’t buy that you corrected a symptomatic hypokalemia with a “couple handfuls of baby spinach”.

It was a regular doctor's visit with my primary care.

My point is that a lot of doctors don't try to root cause problems, they just look at the most obvious symptoms and send patients on their way.

Not bothering to figure out why my BP was dangerously high was, odd, to say the least.

A bag of baby spinach can provide the entire RDA for potassium. Go a couple weeks with 0 potassium in your diet (it requires effort, oops on my part) and see what happens. (I'd been working on an eggplant curry recipe literally every night for a couple weeks trying to get it perfect) thankfully such dietary stupidity is easily fixed.

As another example I just witnessed a case of roseola being misdiagnosed as an ear infection.

My primary care doc misdiagnosed a leg length difference as arthritis in one of my knee joints. (Pain was due to muscle imbalance causing the knee to be pulled out of position, I visited a podiatrist and he was a bit upset at my primary care doctor...)

You may be a good doctor who does proper investigations, but my point is a lot of people have encountered doctors with very bad diagnostic abilities, or doctors who just ignore them outright.

This is incorrect.

I’ve treated hypokalemia in thousands of patients. It takes days with oral routes.

Also, a BP of 160 is not dangerously high. Particularly if you are young, healthy or known to the doctor as it is most likely white coat.

I could describe out the flaws in the leg length discrepancy and your podiatrists argument but I think I’ve made my point.

I have repeatedly demonstrated your believed truths to be largely invalid yet you feel the confidence to speak with absolute certainty, as if your experience is ground truth.

Please stop spreading falsehoods and vitriol about my profession. I have sacrificed over a decade and given up a more lucrative career to help others and your actions are dismissive.

If you have had multiple expert opinions (I.e. not he said she said with podiatrist and doctor) or a legal proceeding demonstrate your doctor was negligent then please don’t speak as your opinion is medical truth.

Edit: On second thought I can’t believe I responded seriously to a poster who thinks they gave himself symptomatic hypokalemia because they were “testing an eggplant curry recipe literally every night for a couple of weeks” and treated it by eating a single bag of baby spinach.

This is obviously a joke, right…? You do know that eggplant contains potassium..?

How did you confirm the potassium deficiency? How low was it?

At the time I carefully tracked everything I ate and realized I hadn't consumed any potassium for a couple weeks, but had a high salt intake.

Lots of sodium, no potassium, things get out of wack quickly.

Ah, ok, so it was just bullshit. It’s virtually impossible to become hypokalemic from dietary insufficiency alone if maintaining caloric needs unless you’re puking or shitting your guts out or have certain endocrine or renal chronic illnesses - not over 2 weeks. And a headache is entirely non-specific - it may have completely resolved on its own as they usually do. We have to meet a certain rigor - we can’t just say oh headache it must have been some dietary indiscretions and low potassium with no evidence - that’s not how any of this works.

If you were critically and symptomatically hypokalemic a couple handfuls of baby spinach would not have corrected that deficit.

> Lots of sodium, no potassium, things get out of wack quickly

If you don’t have an endocrine or renal disorder or taking certain medications - no, they really don’t.

Sitting in the position of the doctor - there’s no way to counter this. You immediately jump to the conclusion you’re symptomatically having headaches because of hypokalemia based on no evidence whatsoever and just a coincidental diet pattern but with no concept of potassium homeostasis - there’s really not much I can do to convince you otherwise if you are inclined to jump to conclusions that quickly. It isn’t supported by basic biology and a practitioner actually has to show some consideration in their diagnosis. You’re going to chalk it up as being ignored. And there we are.

When somebody generally healthy comes in with an episode of a non alarming headache - conservative management is the evidence based standard of care. Come in for follow-up make sure the BP was a transient thing. Maybe have you do some home monitoring. Perhaps your diet is shit, but the potassium would likely not be the problem.

If you really think you’re chronically hypokalemic - maybe get a basic blood test (you can order them yourselves these days - take it when you think It’s low) and take it to a doctor if it’s low. I’m sure it’ll be normal though - and you will have no further diagnosed your headache - just like your doctor.

Also 160/90 is not a great blood pressure to be living with day to day - but it is not "dangerously" high - or what we would call urgent or emergent. BP can be transiently elevated in pain or stress states and 160/90 isn't going to kill you. If you keep coming in with that or better yet you have multiple readings at home like that, we'll talk about lifestyle changes and then maybe talk about a chronic BP medication. But there is no reflex reason to do any lab workup just because a BP is 160/90.

What is considered safe blood pressure and how we should control it both chronically and acutely is something that has undergone a stupendous amount of thought and research since hypertension became a major health concern 75-80 years ago. Not immediately doing every lab test and imaging study in the book for a one time BP reading that high is not based on some capriciousness - it's based on some of the most basic and well-trodden evidence based medicine. It's not as cavalier as the assumption of many here.

Right idea generally but in that scenario it would be like making a diagnosis of alopecia which just means hair loss. In any case some diagnoses don’t have clear explanations or subdivisions for decades or centuries until explanatory medical science catches up with the descriptive diagnoses like anemia or alopecia.