Liberal Arts Blog — How Doctors Think: “I am tired of living in pain” (Part Four)

Liberal Arts Blog — Wednesday is the Joy of Science, Engineering, and Technology Day

Today’s Topic — How Doctors Think (“Medical Mysteries”): “I am tired of living in pain” (Part Four)

So, back to Luisa, the patient with the constant abdominal pain that’s driving her nuts. This is the fourth episode of the first in a series of case studies designed to illustrate how the thinking process of a physician replicates the basic steps of the scientific method. Gather data, come up with hypotheses, test them. Repeat. So far we’ve been through the first 9 steps of my 10 step model of physician practice. Today, the climactic moment. The denouement. The real culprit exposed. Experts — please chime in. Correct, elaborate, elucidate.

Recap: Luisa has in the past been diagnosed by specialists as having irritable bowel syndrome and depression. But medication taken for each has not worked and she has stopped taking them. What could be going wrong? The ROS (“Review of Symptoms”) showed no fever, no vomiting, no nausea, no pain during urination, thereby, eliminating many suspects from the list of possible diagnoses (called “the Differential”). The family and medical history has revealed little. The physical exam has revealed normal vital signs, a clear chest, no rashes, but the rectal and gynecological exams were deferred. The labs: blood tests and abdominal and pelvic ultrasounds — all normal. One puzzling symptom: dyschezia (painful defecation) without constipation. Could this be psychological?


1. So Luisa, when did you last see a gynecologist?

2. Several years ago when I went to see her for infertility treatment which did not work out.

3. And, by the way, sexual intercourse has been painful for the last few years.

Eureka! The triad of painful intercourse, painful defecation without constipation, and infertility is the package of symptoms characteristic of endometriosis — a condition where cells like those of the endometrium (the inner lining of the uterus) appear outside the uterus in places they should not be — so-called, ectopic tissue. These bleed and scar causing pain wherever they are and interfere with fertility in 30–40% of cases.

LESSONS OF THE CASE: Don’t hide embarrassing facts. Don’t avoid embarrassing questions.

1. Doctors, as well as patients, can avoid embarrassing topics. Not a good idea.

2. Rectal and gynecological exams can be avoided. Not a good idea.

3. What is true in medicine is also true in other contexts — marriages, families, and schools come to mind. Avoiding inconvenient facts is not a recipe for moving forward. An Ethiopian saying: “He who conceals his disease can not expect to be cured.”

SOME FACTS ABOUT ENDOMETRIOSIS — low fatality but huge amounts of pain

1. Affects perhaps 6–15% of women. 25% of these have no symptoms.

2. 50% have infertility. 85% of those with infertility have no pain.

3. Historical cases go back thousands of years. Often misdiagnosed as “hysteria.” First identified microscopically in 1860. Two pioneers in the diagnosis of endometriosis in the 20th century were gynecologists Thomas Cullen and John Sampson. Still often misdiagnosed.

NB: The diagram above shows possible locations for endometrial tissue.


Endometriosis — Symptoms and causes

Thomas Stephen Cullen

John A. Sampson



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