Back Pain

SPEAKER_01 0:11

Hello and welcome to a new episode of Home of Medicine Podcast in Association with Royal College of Physicians Edinburgh. My name is Ben Lovell, and I'm a consultant in acute medicine working in London, and I'm joined by my co-host.

SPEAKER_00 0:26

Hi, I'm Dr. Amy Beverbridge, also a consultant in acute and general medicine and director of professional development at Lincoln Medical School.

SPEAKER_01 0:36

Lest we forget, and we're very, very proud of you. So I've got a case for you this week, Amy, and it's a bit different to usual because we normally do cases, new cases that present to us via the take or via same-day emergency care. But of course, another big part of the acute medic's job is the acute medicine unit, the ward. And this is a a patient who I, inverted commas, inherited when I began my AMU week. It'd already been on the ward for a day or so, but been admitted, been clerk, and post-taken by a colleague, was admitted the AMU. And then I come on a Monday morning and I do my ward round and I'm meeting for the first time. And it's a 49-year-old chap. And this man, I think, was on day two of his admission now. And he was admitted with a flare of his severe chronic back pain. So bad that he was unable to mobilize at home because the pain was so bad. And this is a gentleman who had unfortunately lived with back pain for a very long time. He was well known to our complex pain clinic here. And he'd had multiple previous MRIs of his spine. The most recent was just two months ago. And it confirmed he had multi-disc degeneration with multiple site ridiculopathies in the lumbar spine, with compressed discs that were irritating L3 and L4 bilaterally, which was the cause of all of his pain. And he was unknown as yet to the neurosurgeons, and the plan was to marry this conservatively, but he lived with back pain. And he did get flares. He'd previously tried um nerve root injections by the uh the pain team as an outpatient, but unfortunately, he'd never had any decent response to this. And he'd also um was taking quite a lot of medications for this. He was on gabapentin, 900 milligrams three times a day, and ametryptalin, 50 milligrams at night. So big, big doses of neuropathic pain meds. But this pain flare, like his previous pain flares, was so severe he had taken to his bed at home and couldn't even get out of bed to walk to the loo. So he was seen in the emergency department, referred to the medics on the basis of poorly controlled pain or suboptimally, let's say. And despite the best efforts of the clerking team to turn him around and get him home again, he was admitted as unable to carry out any tasks, um of activities of daily living at home, uh, and was admitted to the acute medicine unit where you're taken to his bed and then the next morning met yours truly. So is this a case, a sort of case you're familiar with uh as a as a consultant in acute medicine? You've met patients like this before, and if so, what's your what's your thought process here and what's your usual strategy?

SPEAKER_00 3:25

Absolutely. I have seen patients with very similar presenting complaints with chronic, whether it be chronic back pain, it could be chronic pain that's not managed adequately. And I always like to think that if somebody's in pain, we're not, we're not, well, we're not doing our job because nobody should be in pain. There should be enough pain control and options available out there for people to be able to be pain-free. But I know that in reality, that's not exactly correct. My job as an acute physician is to make sure that this gentleman does not have an acute cause of the back pain. What I don't want to do is to assume that this is a flair of chronic back pain. Just because he's known to have all of these complicated spinal problems, ridiculopathy, multidis degeneration, it doesn't mean that this isn't something completely new. So I want to go back to the beginning. Is could this be called aquina? Is this definitely something that is happening in the spine, or is it something that is muscular? Could it be sacral region? Is this an infection? Is this a fracture? Anyone who's got this level of degeneration is probably gonna have some osteopenia. Could he have an osteoporotic fracture? 49-year-old man, it's unusual, but think about it. Think about any trauma that he could have had. Has he been taking the medication? Has he been able to absorb the medication, or has he had any recent illness that has meant he hasn't taken it or not absorbing it? Any diarrhea and vomiting, for example. I also want to know does he have any other sounds and symptoms apart from the back pain, fever, weight loss, appetite, breathing problems, any changes in bowel habit, any chest pain, any shortness of breath? So, really, I don't want to assume that this is all due to the chronic back pain, because well, that's easy, isn't it? It's easy for us to do that.

SPEAKER_01 5:40

What's wrong with easy?

SPEAKER_00 5:42

Nothing is wrong with easy, and that's what I need to stop. I make my life really hard in all areas of my life, not just medicine. And you know what? Sometimes maybe I should just go, This is chronic back pain, pain relief, observe home. But I'm like, no, there must be something else going on here. I must spend two hours figuring out what's going on. Uh, it's my mind, it's the way it works. I've tried to change, I can't change, Ben.

SPEAKER_01 6:08

I think there's some really good stuff from what you say, and I think you're right in that if someone someone comes in with um a condition they've presented with many times before, we have to check it fits the pattern. Um, because of course they can come up with something new.

SPEAKER_00 6:22

Absolutely.

SPEAKER_01 6:23

Um, so I think checking that it fits the pattern, and the way I check it fits the pattern is by asking the patient.

SPEAKER_00 6:29

Yeah.

SPEAKER_01 6:29

Um, and you know, whether it's someone who's coming with a flare of um chronic, oh, I'll tell you what I see a lot of um people who come in with a flare-up of um psychic or vomiting syndrome, so severe abdominal pain and can't keep anything down. And I I I see that quite a lot. So most of those people do, in fact, have a flare-up of this condition which waxes and wanes. But every now and again, someone will have something else, they'll have a gastroenteritis or something, or more sinister pathology there. So, my process to say, does this feel like your usual flare of X and let the patient tell me? Um, your other question about was he taking his medications, or if so, was he keeping them down? Was he vomiting or anything? He was taking those meds and he he wanted more. Um uh the handover I got was that he he is asking for morphine and oromorph and uh and morphine preparations because his pain is very, very bad. So we can talk maybe a little bit about how to manage flare of chronic pain some um the do's and the don'ts. Um in fact, let's talk about it now. So, one of the things I hate to do with people who truly have a flare of a chronic pain syndrome because it does them so much harm is admit them to an inpatient bed because it is very difficult to suppress a flare when you do what all patients do in hospital, which is lie completely flat for 23 hours a day. Once you stop walking around and getting up and going to the loo, everything sort of freezes in position. I see it's a lot with back pain as well. So, my first goal, once I've satisfied myself that this is a pattern, this is a flare of a chronic pain syndrome, is to do everything I can to try and avoid them coming into hospital. But that's not always possible. Um, the other thing I do is think about pain medications. We have really good links with our pain team in my hospital, the complex pain team. And people who do have chronic pain disorder sometimes have a pain plan um in their notes somewhere saying when they do present acutely via ED with a flare up of chronic pain, here's a few things that you should try and things that maybe you shouldn't try. And the one thing, um, and they're really, really helpful. And one thing they often say, the chronic pain team is do try to avoid starting them on opiates, particularly long-acting opiates. And that's not out of any sense of denying patients uh a comfort or pain relief who are suffering. It's about trying to balance short-term versus long-term problems. Um, and they have enough evidence to know that when you start um opiate preparation, particularly long-acting and modified release ones, it actually sends them down on a downward trajectory over time, months and years, very difficult to get them stopped again. It um affects their pain threshold, which means that the further um flare-ups of pain need to meet bigger and bigger doses. We did go through a period maybe 10, 15 years ago, where I'd meet people who were taking MST, morphine sulfate tablets, on something like 150 milligrams twice a day, just to feel normal, because those medications had been started by um well-meaning people trying to get them more comfortable. So I would check the pain, uh, you know, see whether if they were known to the pain team, did they have a good pain plan for how to get on top of a flare like this? Um, but going back to this particular case, I went to meet the patient and I said to him, Does this feel like your normal pain flare out? This is your pain times 100. Is that right? He said, Absolutely, yes, but this is the worst it's been. But it's the same place and it's killing me. I want an MOI and I need some morphine. Very clear with what he wanted. Um, and he'd been seen by our therapists to see what he was like on his feet. And they said, we couldn't even get him out of bed. He was in so much pain, he's refusing to walk. Maybe we'll come back later after he's had a good dose of some um maybe some oromorph or something, we'll try him again and see what he can and can't do. But he is usually independent at home and he's a long, long way from that particular baseline. So let's pause there for a second. Any thoughts?

SPEAKER_00 10:33

Oh, many, many, many. Um what I think we have to be very careful not to do is to underestimate people's pain and to say to people, you can't be in that much pain, it can't be that painful. Because who are we to question that? Pain is a very subjective sensation, not an objective sensation, it's subjective. But on the opposite side of things as well, I guess the question I want to ask is what do you want me to do? He wants an MRI, he wants some pain relief. I'm gonna do that because he's in pain and he's telling me he's in pain and he's asking for an MRI. His last one was two months ago, it's worse than ever. How do I know something acute hasn't happened? I guess on the in the back of my mind is is this medication-seeking behavior? But I can't say that after meeting this individual once, and I don't want to stereotype and I don't want to pass that judgment, so it's really difficult. I find these cases incredibly challenging.

SPEAKER_02 11:59

Yeah, um, they are really, really difficult.

SPEAKER_00 12:02

And I don't think there is a right way of doing things, I think there are very wrong ways of doing things, but not necessarily. I think we can all do manage it in a slightly different way, but it'll all be the right way if that makes sense.

SPEAKER_01 12:17

I've been on the other side. Um, I've been a patient and had horrendous pain. I had to have an operation. And um, after the operation, the pain was more than I envisioned it could be. And I remember being quite struck by I wanted to I wanted to ask for pain control, but it does sound so funny when you ask for strong painkillers. It sounds funny, it sounds like you're drug seeking, and I was drug seeking because I was in agony. I was seeking a drug. So, but it sounds it's even by uh in my own ears saying, Look, you're giving me dihydrocodeine, I'm in uh severe pain, I'm in eight out of ten pain. Um, I need something stronger. And you know, maybe it was all in my head, but were they looking at me funny? Were they writing something in my notes? And I was struck with by being told by medical and nursing staff um a couple of interesting sentences. What one was, but people aren't usually in this much pain after this procedure, was one. I don't know what I'm supposed to do with that information. And the other one was, but most people aren't in this much pain after they've had this much painkiller. Again, well, I must be your outlier. Maybe I'm a wimp. I'm so I'm so sorry, but I'm not asking for a script to take home with me. I'm asking, could you get me through the next 12 hours through the night without with the state of, you know, curled up in the feet position, shaking in agony. But um, I was denied that pain. So it sort of changed it, it changed me a little bit um about how I approach pain and patience. This is quite a few years ago, it happened to me. And if a patient is says I'm in agonizing pain, I have absolutely no way of disproving this. Of course. Uh and why should I uh try and disprove it anyway? Um, but you're right, there are a few, there are a few wrong things to do, and I wanted to get it right. And I think the wrong things to do would be, I feel like the wrong thing to do would be just okay, let's just keep give giving you um injections of morphine to to you till you're not in pain anymore. Because you know, it that that carries risk, short-term risk. Um, I don't think people coming back to me and saying, hey, that guy you gave 10 milligrams of iv morphine to, but he won't wake up and his pupils are pinpointing his respiratory rate's four. Um, and also I don't want him to be in a position saying, I only feel good now I've had the morphine. I'd like I need it. How how do I wean that? Um it's easier if someone's got an acute injury, a trauma, a broken bone, a surgery, and thinking, okay, a bit of strong morphine for for the next few days, it sounds reasonable to me until the body starts to heal. But a flare of a chronic condition, then I do worry about introducing a potent opiate to the mix because I don't know if that helps in getting them back into remission again. And I don't know what happens the next time they get a flare up, if anything will suffice except the morphine, except maybe next time it's got to be 15 milligrams. So I'm worried about future him as well as current him. I always think the wrong thing to do, and I've seen this approach before, is saying, well, I can't give you any of the stronger painkiller because I'm looking at your pain plan here from the pain clinic, the pain team, and they're saying that we're not allowed to give you morphine. So what can I do? Yeah, that sort of splitting of teams and making one team a bad guy, and I'm the good guy, um, doesn't help anybody down the line with that patient's relationships with the hospital. Um so I I said to the patients, well, and another question I ask patients, you know, with flares of chronic pain is how long does it normally take you to turn the corner when your condition flares up like this? How many days? And if they say it's usually minimum three days in hospital and then another week after that, that helps me sort of measure a bit and saying, okay, we're on day two now. I'm really hopeful you're gonna start to turn the corner in the next 24 hours. Let's just see what we can do to make you a bit more comfortable today and give it a bit of time. I won't push the physio today if you simply are not up to it, but we've got to try tomorrow morning, haven't we? Because I don't want you to, you know, be stuck in your bed and then get all sorts of problems with back pains, you know, the circulation and blood clots and all that sort of thing. So why don't we make a deal to leave you beat today, see what you can get some rest and get some food into you, and then tomorrow we'll meet again and see if you're in a better place to get up and start moving around very, very gently. Um, and see if that brings them any sort of relief or comfort. Um, and sometimes you can fashit out a plan like that. Um, and I said to him, I don't think we need to do the MRI because you've had a lot of MRIs in the past. The most recent was two months ago, and it gave us the answer. We do MRIs to get an answer. You know, MRIs are not a therapeutic intervention, you know. Although I wonder if some people feel a bit better after they had one because it takes away anxiety. But I don't need to an MRI to make you feel better. I do an MRI if I want to ask a question, why are you in such terrific back pain? But I actually know the answer, don't I? The MRI two months ago showed me I know why you're in terrific back pain. You've got all these horrible bulging discs and these compression ridiculopathies, and you've got nerve roots being touched and irritated by by discs, and that, and and you and it flares up and it settles down, it flares up and it settles down. I've got the clinical answer I need, so that's why I don't think I need to push for an MRI today. And I hope you think I'm being reasonable with that. I say to the patient. Um and um and yeah, so that was my sort of approach on the ward round. A bit longer than it normally takes, and but these aren't the cases where you it's a quick in and out.

SPEAKER_00 17:36

How do you know that there wasn't anything new going on?

SPEAKER_01 17:42

I guess I use my clinical clinical deduction. I ask the patient, maybe you know, when I'm saying, does this feel like your usual flare up, which happens every few months, or does it feel like something new is going on? That can be quite telling. If they say, I've never had this numbness going down one leg before. Well, okay, all right, that's new. I've never lost control of my bladder before, I've never had these fevers before, I've never vomited before. Those sorts of things would say, okay, this sounds new. So it's red flags. Yeah, if it's ticking all the boxes for their usual flair up, maybe I've met them before on their previous admissions. I've been in the same hospital for yonks now. I I know some of these patients. Um, so I use a bit of judgment. Um of course I should always examine my patient and look at their vital signs. And I did look at this chap's vital signs, they were all within range, they were all normal. I examined his legs. I always examine the legs and people with back pain, particularly when they've got known dodgy spines. Um, and I couldn't detect any abnormal neurology, but he was in so much pain, he didn't, he was not really able or willing to lift this leg in the air, now push this leg down again, now bend the knee, now push against my hand. It was all a bit too much for him, pain-wise. Um, he'd been examined head to toe by the admitting doctor and Zen seen on the post-take ward round, and they'd examined his neurology, so that was reassuring.

SPEAKER_00 19:02

Okay. So are you what are you challenging here? Are you thinking maybe this patient shouldn't have been admitted to hospital at all? Would you have sent him home at the front door?

SPEAKER_01 19:14

I doubt I would have been able to. I always say to um doctors who on post-it board and just say, Oh my gosh, I'm really sorry about this next one. I wanted to send them home, but I couldn't as and I would say, listen, I'm never gonna give you a hard time for admitting a patient if you thought that was the safest thing to do. Please don't, you don't have to apologize for doing it. Um and sometimes you can't. And what are you gonna do if you can't walk? Put him in a wheelchair, wheel him to the pavement and just say bon voyage, you know, and just leave him on the street. You you can't do it. Um so so sometimes you absolutely you absolutely can't. So there we go. So I said to him, let's try again tomorrow. Okay, stay in bed today. And and I met him on the wardround the next day, and he was still in severe pain. He'd have some blood stunned on this. This is day three now. His CRP was 104. It was normal on admission. I thought that's interesting.

SPEAKER_00 20:10

Okay, that is interesting.

SPEAKER_01 20:12

Yeah. Why why is it interesting to you? And I'll tell you why it was interesting to me.

SPEAKER_00 20:17

So see up, we've talked about CRP quite a lot. Well, I think we like talking about CRP, don't we? So CRP of 104 is pathological, I think. It's higher than, you know, if it's like 40, 50, I'm like, yeah. 104, I'm thinking there's some level of inflammation going on in the body somewhere. Is this infective inflammation? Is this localized inflammation within the spine? Is it irritation? So I want to do a full set of blood surgeries. I'd want to look at his white cell count, his neutrophils. I want to look at his kidney function, his liver function. And I want to think about okay, CRP, has this gone up because he's got a fracture? Check his alk FOS or has it got an infection? Has he got an infection elsewhere? Is it viral? Or does he have a spinal infection, such as a dyskitis? Or does he have a DVT? He's been immobile for quite a long time that can push your CRP up sometimes. Does he have a pneumonia? Although he's only been in hospital for 24, 48 hours, someone likely to be a hospital acquired pneumonia. So I wouldn't that would it wouldn't concern me too much, but because he was still in bed, he was still unwell, and he said this is the worst pain he's had. I need to know that there's nothing in that spine that's causing the CRP.

SPEAKER_01 21:52

I remember learning in medical school back pain and high CRP equals disgitis until it's proven otherwise. It doesn't really bear out in real life. I have to say, but you do have to think about it absolutely. So I went to the patient again and I played Hunt the Infection. And the first thing I did was uh was palpate his spine because when you have disgitis, you cannot bear anyone touching your spine, right? It's it's really, really tender.

SPEAKER_00 22:14

Absolutely.

SPEAKER_01 22:14

And also I wanted to have a look at his back. I like to look at the painful bits of the patient. We've we've talked before about missing zoster, herpes zoster. A nasty attack of shingles can cause terrific pain. And if you don't actually visualize the skin, you can miss it. So I went to his bedside, I said, roll over, had a look at his back, no shingles there that could explain this horrible back pain. And I give, I mean, his back was tender, but not desperately so. And I pressed up and down his spine with my thumb, and then I went on the paraspinal muscles as well. And it was tender, but he wasn't screaming in pain, um, but it hurt. I asked him about urinary symptoms, I asked him about chest symptoms, um, and I had a look at his skin, and I found a pat I found the cause really. Um he had a patch of cellulitis on his left leg, spreading up from the foot, which I wasn't entirely sure had been there yesterday because it was hiding under his compression stocking. But there you go. He had a patch of cellulitis, and I said, okay, this explains. And I said to him, actually, this might partially explain why why you're in so much, why you're having a really bad flare-up. We know that chronic um pain can flare up during intercurrent infections. Um, so I thought if you're having a systemic response to a skin infection, maybe that's why your pain's a bit higher than it usually is. But a bit of flu cloxicillin, and let's keep an eye on this. And I started on flu clocks, um, and I drew around the cellulitis, and I went on with my wardround.

SPEAKER_00 23:44

This feels it's like when you say to me, it doesn't feel there's something missing. Or am I is that just my bias because we're talking about it on the podcast?

SPEAKER_01 23:55

That's exactly what I was gonna say. Do you think we think that though? Because we've brought this case to the podcast. Like, what's what's the function here?

SPEAKER_00 24:02

Yeah, but I I think it's it feels incomplete, I guess, for me. Um, I mean, the fact that he you said that he rolled over is a good sign because obviously he was able to mobilize his spine. Um disgitis. I've seen I've seen a fair few cases of disguitis actually. Um, and I'm sure we'll talk about some of those actually in some upcoming episodes. Um, but they're certainly in a huge amount of pain, and they've all had spinal tenderness. When you tap down the back of the spine, that spinal tenderness has been there. What was his white cell count and neutrophil count like?

SPEAKER_01 24:40

Normal.

SPEAKER_00 24:41

Okay.

SPEAKER_01 24:42

And the rest of his blood tests are normal also.

SPEAKER_00 24:44

Okay, so with dischitis, it tends to be a lot higher because they really they often vary unwell as well, particularly if it's associated with TB of the spine, can be quite problematic. Okay. Why did he have cellulitis? He's 49 years old.

SPEAKER_01 24:58

That's a good question, actually. We often stop when we think cellulitis, but you should look for the skin breach, shouldn't you?

SPEAKER_00 25:02

Yeah, was he diabetic? Did he have athlete foot?

SPEAKER_01 25:06

Um, he didn't have athlete's foot. So you're right. You need to you need to look for the insect bite or the scrape or the cut or the athlete's foot, don't you?

SPEAKER_00 25:15

Look in between the toes, yeah.

SPEAKER_01 25:16

Yeah, exactly. Good thoughts. I um I moved on, and um, it wasn't till the afternoon where his bedside nurse came to me and said, There's something wrong with this man. I I met him the day he came in, and he was not this bad. He won't even allow the bed to be raised up so he can eat his lunch. He's lying completely flat and like log rolling himself from side to side. He was never like this before. So she said, and she hadn't worked for two days. She said she saw him on day one and then she saw him now. She was really shocked by how bad his pain was. Um, so I delegated. I said to the SHO who was looking after that particular bear, I said, just go back and have another look at him. I know we've looked at him 20 times. Um, just go back and have another look because the nurse is worried. And they went away for about half an hour and they came back and they said, I've just done a neuro exam of his lower limb. He's got complete sensory loss from L3 down on his left leg.

unknown 26:12

Okay.

SPEAKER_01 26:13

Um, and I said, I said, since when? Um, because he had a good neural exam on admission and a post tape board round. My neuro exam yesterday was rubbish because he's in so much pain. And I and it was a cursory motor-based one. Can you do this? Can you lift this? Can you move this? Does your are your reflex intact? I didn't do pinprint, I didn't check his sensation going up the leg. Um, so at that point, I was like, Do you know what? We need the MRI spine.

SPEAKER_00 26:41

Absolutely. Yeah.

SPEAKER_01 26:42

Now something has changed. And we got an MRI spine that day. And this is a great report. Well, no, it's not great for the patient, unfortunately. Multi-level diskitis with vertebral osteomyelitis and query impending canal stenosis at the lumbar spine. Recommend discussion with neurosurgeons.

SPEAKER_00 27:04

Gosh.

SPEAKER_01 27:05

Spoke to neurosurgeons, doesn't need surgery, conservative treatment, spoke to ID, who took over his care, already on the right, antibiotics, flu clocks, they escalated it to two grams QDS and they admit into their ward. Um and and there's a lot to think about there, isn't there? Because what should I or could I have done differently in this patient? Um, if we were going to join all the dots of this timeline. I mean, the patient said to me, I'd like an MRI, please, and I I explained why not. But um what did I where had I gone wrong? Cognitively speaking. I think the first thing that shocked me was someone who had cro recurrent flares of chronic degenerative spinal pain, came in with a absolute pattern fitting their their acute flare, but this time had a rare condition associated with it. I guess that's Hickam.

SPEAKER_00 28:04

Yeah.

SPEAKER_01 28:06

He can have as many diseases as he pleases. Um, but it was a zebra rather than a horse.

SPEAKER_00 28:12

It was a zebra, yeah.

SPEAKER_01 28:14

Um, the first thing was something else that made oof sounds. Um he had he he he he didn't have that CRP of 400 and this screamingly tender spine, which I associate with the skytis, that fits with my illness script for discussion.

SPEAKER_00 28:31

Yeah, absolutely. Yeah, yeah.

SPEAKER_01 28:33

That that was that sort of maybe drew me off on a different path. I think looking back, the cellulitis became a satisficing diagnosis.

SPEAKER_02 28:42

Yeah.

SPEAKER_01 28:42

Now, if you're gonna challenge me on the word um satisficing not being a word, go back and listen to our episode with the Pat Cross Carey, who taught us about surf satisfacing in human factors and cognitive bias and how you can, and when you find a diagnosis which explains things away, you can stop thinking. Um premature closure as well. So there's quite a few things to unpick there for me. Um, one thing I'm relieved about is that I hadn't caused this patient long-term harm. If they'd said transfer urgently for immediate decompressive neurosurgery, I would have been horrified. They would have thought I should have done this yesterday. Um, and and the fact that the treatment plan was sort of more or less unchanged moving forward, you know, brought my blood pressure down a little bit. But it's it's not good. It's not a good feeling when this sort of thing happened. At least I found it and I did make the diagnosis. Could I have done it 24 hours earlier? It's what nags at you, isn't it?

SPEAKER_00 29:37

Um absolutely. Can I ask a maybe slightly challenging question?

SPEAKER_01 29:44

Oh, go on then. It's a safe space. Go on.

SPEAKER_00 29:48

Do you think you had any visceral bias towards this patient because of his chronic back pain?

SPEAKER_01 29:58

I think in the way you mean bias, probably yes. I think if you there's a lay term of bias, which is an extremely negative term, and people think about stereotyping, bias, prejudices. And I honestly don't believe I have a prejudice against people with chronic pain, but maybe I do have uh a bias in how my brain works, my cognitive reasoning, in that I can attribute things towards a chronic illness, which might actually be a new acute illness. I think that's a fair reflection.

SPEAKER_00 30:25

Yeah. It's, I mean, it's a I don't think you did anything wrong, Ben, because we have we see so many patients with back pain or chronic pain in AMU. We see so many patients that we also have to think about the pretest probability. So, what was this pretest probability of this gentleman having dischitis? 49-year-old man, immunosufficient, immunos. I can't think of the other opposite word for immunosuppressed, immunocompetence, immunosufficient, what I'm going about, immunocompetence. Um, had no history of disgitis, was well in himself, and so actually his pretest probability of this gentleman having dischitis was low. I agree. And then something changed. And that's the key thing I think that as physicians we need to do is if something's changed, and that's when we need to re-question. And when it changed, the pretest probability went up, didn't it? Because his CRP was high, he had pain, more pain, he had change in sensation. The pretest probability of this being disguitis was higher, hence MRI.

SPEAKER_01 31:47

I don't beat myself up too much because I've got quite a my my view is I I saw 150 patients that week, and this is the one, yeah, the one. And and I am absolutely not perfect, and I'm not all-knowing. Um, I'm a human being who's doing his best with the training that I've received.

SPEAKER_00 32:06

Exactly.

SPEAKER_01 32:06

And um, so so I don't give myself a heart, but I do like to try and learn and reflect and think, Ben, what what could you have done differently then? You you might you might post to be, but I don't want to get just to the state where I'm over-analyzing and over-imaging and over-investigating everyone. Because what's what's next? You know, if we come in with a flare of their um psychical vomiting syndrome and I'm ordering inpatient OGDs to rule out obstruction, how do we get to that space? I want to keep a healthy sort of overview of it. But I guess it certainly made me a bit more wary about disguitis now. Maybe that old adage from medical school, you know, the high CRP and back pain, it's disguise for proven otherwise. Well, not wholly true. Maybe I shouldn't have thrown it out of the window in its entirety to kick off with. Why did I do that? Probably because I rarely see disguitis and I see a lot of back pains, and I see a lot of degenerative spines and ridiculopathies, and it's painful and it's common. Exactly. And I I felt I felt safe to close, to close my prematurely, to but to close at that point.

SPEAKER_00 33:14

And as you said, common things are common and rare things are rare, and we can't think everything's rare. We can't diagnose everybody with a rare condition, can we? Because we don't have the resources, the space. And actually, sometimes we'll be putting people through unnecessary investigations and tests and treatment when they don't need it.

SPEAKER_02 33:34

Yeah.

SPEAKER_00 33:35

I think that's one of the hardest parts of medicine for me is thinking about what investigations people need, why do they need them? What happens if we don't do them? What's the pretest probability? And I think that's where I spend a lot of time on that investigation.

SPEAKER_01 33:58

What does the patient want, or what does the patient think they need?

SPEAKER_00 34:01

Exactly. And that's a really important question. Yeah.

SPEAKER_01 34:04

Yeah.

SPEAKER_00 34:05

Yeah, yeah, yeah. And I think that brings into the final when we think about clinical reasoning, you know, shared decision making is a big portion of that. And often we talk a lot about how we've made these decisions and we've thought about it. What does the patient want? The patient wanted an MRI. Um, and I'm not saying that's was the right thing or not, but it's the same with cases that I've seen that the patient didn't want the doac. What do you do? Do you not give them the DOAC? And it's it's how we then manage, we've got the diagnosis, and then how do we manage the management of it, you know, with that shared decision-making framework in mind?

SPEAKER_01 34:42

And of course, sort of medically speaking, patients can, if they're of sound mind, they can decline any intervention that they like. Yeah, but they can't request one, they can't demand one if a doctor doesn't think it's right. So, in that sort of way, we hold a lot of power on the patient doctor dynamic. We hold the cues to the kingdom, and that's why some patients think they have to come in and beg or maybe beef up their symptoms a bit, because they they think this is what I need. How do I convince this person to let me have it? And and I think as a human being, sometimes doctors, we know when that's happening, and it can sometimes put us a bit on the back foot, or even sometimes put us on the defensive a little bit, and make us make us sort of uh double down um and say, you know, I've said I've said no, I'm not gonna change my mind, and I'm sorry we haven't agreed on this. I'm sure we've done a podcast episode on this before where we haven't quite come to a happy consultation that we've really liked.

SPEAKER_00 35:37

Yeah.

SPEAKER_01 35:37

Um and I think, and I don't want people to come away from this thinking the patient always knows, always give the patient what they want. That's not the moral of this story, I think. Um, I think the patients have some really good ideas, and we have we have a duty to listen to them and then explain what we think we're gonna put it needs to happen and what we're gonna do next. Um, but it should be a collaborative decision as best as you can make it.

SPEAKER_00 36:01

Yeah, absolutely.

SPEAKER_01 36:04

Easier said than done.

SPEAKER_00 36:05

That is not where I thought that was going.

SPEAKER_01 36:09

You called it. I mean, you said disguises great and the way it goes. Um, but uh there you go. But it's nice, I think, for people to hear two different thought processes on this and in parallel. Well, thank you for playing along with me today, Amy. I hope you enjoyed that case. What was the difference?

SPEAKER_00 36:25

It was really different actually. I really enjoyed it. I think it's it I think it uses a different part of my brain, you know, when we talk about different things and because we do think quite differently. It's good to vocalize how both of us have completely different thoughts. We end we usually end up with the same endpoint. We just get to it a very different route. Yeah, I go around the roundabout 72 times and you're down the M6. It's fine. We get there.

SPEAKER_01 36:50

I was gonna say there are many different paths to the top of the mountain, but um, get to the mountain. But yes, you're and your your M6 analogy sort of like anyway. Let's uh let's wrap it up there. Um, thank you everyone for listening. I've enjoyed playing along. Um, maybe you guessed it straight away and you're a better doctor than me, but that's all the fun of the game. And um, please do tell your friends about our podcast. We love to grow and we're getting bigger and bigger and bigger. It's a very little podcast that we do sitting at our kitchen tables, but we love doing it and we love getting your feedback. So please do write in if you have an idea about a case or you want to tell us about how you reacted to certain cases. But until next time, it is a big thank you and a goodbye from me.

SPEAKER_00 37:29

Thank you very much. Goodbye.