Anatomy Of A Misdiagnosis

Here, as part of the Institute for Healthcare Improvement's Open School, Academic Advisor James Moses recounts the distressing story of a Lauren Mason, an 18-year-old college freshman with terrible pain on the left side of her face who was misdiagnosed by a reputable ENT specialist at a major Boston teaching hospital.

Dr. Moses interrupts his storytelling periodically with leading questions about Lauren's care (for instance: "Has the case been centered on the patient thus far? Why or why not?" or "If you were Lauren’s ear, nose, and throat specialist, what else would you have said to Lauren’s mother? Would you apologize for the misdiagnosis?") Here's a snippet of Lauren's saga:

During four hours in the office, she endures a long series of tests, including more for her balance and equilibrium. She also spends time in the Audiology Department and gets extensive hearing tests done.

Finally, the doctor diagnoses Lauren with a case of internal shingles in her ear canal. He explains that since she had chicken pox when she was little, she is susceptible to getting shingles. Lauren asks if he can see anything like shingles inside her ear. The doctor says no, but surmises that there was an outburst a few months ago and that the nerve damage was becoming evident now. He explains that it’s a disorder called postherpetic neuralgia and that she may also have trigeminal neuralgia, or unexplained pain that affects parts of the face. The doctor prescribes an anti-seizure medication (to help calm the nerves causing pain), an opiate to help manage the pain, and a stronger painkiller for especially difficult episodes. Lauren is instructed to take the pills three times per day.

The visit ends with the doctor telling Lauren that here is no guarantee the pain will ever go away...

Later:

Lauren goes for an emergency root canal with a local endodontist later that day. The typical amount of Novocain isn’t enough, as Lauren’s tooth has become too infected. The endodontist comments that the infection was close to the jaw bone and, if they hadn’t caught it, would have caused a lot more pain and further complications. The root canal is only the start of a series of dental work, but it greatly reduces Lauren’s pain.

Lauren’s mother calls the ear, nose, and throat specialist in Boston to explain the new situation and asks about the medications Lauren is still taking. The doctor explains that Lauren needs to stay on them for a few more weeks to prevent withdrawal and possible seizures, and must be slowly weaned off of them.

Many of the comments note that the mouth is often overlooked by physicians as a source of potential problems, and several readers say that Lauren's treatment, though unacceptable, is not unusual. Here's one:

I wonder why none of the doctors involved in the misdiagnosis apologized. This is not the case of a single Lauren, there are many Laurens who suffer this type of painful experiences for getting appropriate treatment for other conditions. Nobody asked if she had dental pain at the onset.Nobody listened to Lauren, everybody was trying to treat her pain without looking for all possible causes (differential diagnosis). Lack of care coordination, too much sub specialization, poor communication and poor follow up are all to be blamed in addition to the clinical misdiagnosis. I feel sorry for Lauren.