PUBLIC DECLARATION REGARDING

SCRIPPS CLINIC, GREEN HOSPITAL, LA JOLLA, CALIFORNIA

Laura Walther Nathanson M.D., F. A. A. P.

PACKAGE 4

SUMMARY:

Wikipedia has good definitions of the two terms, “Diagnosis of Exclusion” and “Idiopathic.” 

The term DIAGNOSIS OF EXCLUSION (per exclusionem) refers to a medical condition whose presence cannot be established with complete confidence from examination or testing. Diagnosis is therefore by elimination of other reasonable possibilities.

An example of such a diagnosis is "fever of unknown origin": to explain the cause of elevated temperature the most common causes of unexplained fever (infection, neoplasm, or collagen vascular disease) must be ruled out. Another example is Bell's Palsy.

. . .. Diagnosis by exclusion tends to occur where scientific knowledge is scarce, specifically where the means to verify a diagnosis by an objective method is absent. As a specific diagnosis cannot be confirmed a fall back position is to exclude that group of known causes that may cause a similar clinical presentation.

IDIOPATHIC is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause. From Greek idios (one's own) + pathos (suffering), it means approximately "a disease of its own kind."

It is technically a term from nosology, the classification of disease. For most medical conditions, one or more causes are somewhat understood, but in a certain percentage of people with the condition, the cause may not be readily apparent or characterized. In these cases, the origin of the condition is said to be "idiopathic."

. . . As medical and scientific advances are made with relation to a particular condition or disease, more root causes are discovered, and the percentage of cases designated as idiopathic shrinks.

In his book The Human Body, Isaac Asimov noted a comment about the term "idiopathic" made in the 20th edition of Stedman's Medical Dictionary: "A high-flown term to conceal ignorance."

Chuck’s first diagnosis at Scripps Clinic was Idiopathic Pericardial Effusion. This idiopathic diagnosis was acceded to by all his physicians, radiologist, medical resident, two cardiologists, and his own Internist. 

The diagnosis was made despite the fact that the Resident’s admitting note stated that the most serious possible was malignancy, and that it must be ruled out. It was not ruled out. Indeed, malignancy was never mentioned again by any of these Senior physicians: Drs. Walter Goff, Merri McMahon, Douglas Triffon, and Vivian Terkel.

There are two ways this disaster could have been prevented:  

1. Any one of the physicians involved could have recognized the omission and corrected it.

2. Someone—I, for instance—could have read Chuck’s medical record, easily have found the oversight, and brought it to the attention of his physicians.
   

Chuck’s second diagnosis at Scripps Clinic was a Diagnosis of Exclusion:  Cancer of Unknown Primary Site (CUPS).

This diagnosis was acceded to by  Pulmonologist  Jacqueline Chang M.D., Pathologist Max Elliott, M.D.,  Oncology Resident/Fellow Michael T. Hopkins, M.D. , and Hematolgist-acting-as-oncologist William E. Miller, M.D.

You have already learned about Thymoma and have reviewed Dr. Chang’s pulmonology consult (012A). If you read the “oncology”report of Hopkins and Miller, you may deduce that they based their diagnosis heavily on the biopsy report performed by Pathologist Max Elliott. 

If you can make your way through this report (017), you will see that it lacks at least three features that one might expect in a path report. 

There is no apparent judgment about the size or quality of the biopsy tissue available. However, there is a phrase that may hint at that size and quality: “small to intermediate cells…within a densely sclerotic stroma.” 

So the relevant tissue cells were embedded in a dense,  hardened, “stroma.” What is a stroma? According to Merriam Webster, it is  “The connective tissue framework of an organ, a gland, or other structure, as distinguished from the tissues performing the special function of the organ or part. “ 

There appears to be no reasoning involved.  Since the biopsy was of a mass of the anterior Mediastinum, should there not be a statement about Thymoma—the most likely diagnosis?

What diagnoses have been suggested by the results of previous studies—especially imaging studies? In particular, the differential diagnosis of Chuck’s CT of the chest, which includes Thymoma as a possibility? 

In fact, Chuck and I both were surprised that the diagnosis of Thymoma was never entertained by any of his doctors, other than the radiologist who read his CT scan. Chuck’s maternal grandmother had died at the age of 58 of Malignant Thymoma, and we had told all his doctors this. I asked Dr. Chang, Dr. Miller, and in particular Dr. Max Elliott if it were not a possibility. When they said “No,” but gave no reason, we hurried to seek help at NCI cancer centers: Vanderbilt, in Nashville, and MD Anderson, in Houston. 

At MD Anderson, the diagnosis of Malignant Thymoma led to Chuck’s enrollment in a protocol for potential cure of his advanced disease (000). The initial chemotherapy reduced the tumor in size enough for the vital surgical attempt at total removal—though the surgery was very extensive. All the surgical specimens biopsied revealed “Thymic Cancer/Malignant Thymoma.”(032.)

Five days before Chuck died on June 5, 2003, he had a high resolution MRI that showed him to be entirely cancer free. His death was due to a massive pulmonary hemorrhage, a complication of the necessarily extensive surgery and intensive radiation therapy.

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