Last night when I got home I was emotionally burnt-out. I had done an all-day clinic and saw many difficult and challenging patients with MS, both new and follow-up patients. My wife asked me if I had a good day. I replied that it had been exhausting and that I felt numb. She said there must have been something rewarding in my day’s activities? On reflection, there were a lot of small moments that made me feel I was doing something worthwhile. This is highly relevant because my clinical director has recently recommended I stop seeing patients so that I can focus on research for the last decade of my academic career. The question is am I ready to auction off my vintage patella hammer and ophthalmoscope and not see another patient?
The most satisfied patient I saw yesterday was a young woman in whom I was able to not make the diagnosis of MS. Her white matter lesions were non-specific, her CSF was clear (no oligoclonal IgG bands and normal neurofilament levels), she had a full set of evoked potentials, which were normal, and her neurological examination was entirely normal. She has a positive family history with her mother and aunt having died of the MS-related complications. After presenting with visual and sensory symptoms her previous neurologist had been influenced by the family history and raised the possibility of her having MS. The non-specific white matter lesions on MRI had cemented the possibility in both the referring neurologist’s and the patient’s minds.
The tragedy of this case is that this patient has been living with the possibility of having MS for the last 6 months. Her anxiety levels were sky-high and she had already internalised the diagnosis and had started to behave like someone with a chronic disease. She developed ‘MS-fatigue’, which on reflection was due to anxiety and depression and had tragically turned down a promotion at work that required her to transfer to her company’s office in New York. On reflection, her symptoms were almost certainly due to migraine aura. She was not the only patient to cry in clinic yesterday, the only difference was that her tears were tears of joy.
Not diagnosing MS is easier than undiagnosing MS, which is a topic I teach on frequently. There are many reasons why people are misdiagnosed as having MS, but it is much commoner than you realise. I am not sure if you are aware that if you have MS there is a 1 in 20 chance that you have another disease; if you are interested I have already covered this issue in a previous blog post.