[danachow]

A hemoglobin for 4-5 is anemia - the definition of anemia is low hemoglobin concentration. If your wife had hemoglobin that low, then she was correctly diagnosed with anemia.

It is a bit odd though the apparent coinfection with multiple tick borne illnesses from different species of ticks - A lyme and ehrlichiosis coinfection is not surprising, but rocky mountain spotted fever is a very different illness, often more acute in presentation with distinctive signs and symptoms - but coinfection with the other two would be quite rare.

Also, those specific tick illnesses listed are unlikely to cause that profound of an anemia by themselves, so there's probably some other pathology going on - the tick borne infection may only be a trigger.

Any relatively young person that is otherwise healthy (no near end state kidney disease) should definitely get referral to a hematologist for hemoglobin of 4-5 if it isn't something blindingly obvious like blood loss.

[code_duck]

The difference is actually finding the root cause or just diagnosing what’s essentially a symptom as if it’s unexplained or isolated (idiopathic, I think is the term?).

My mother was diagnosed with anemia, and received many recommendations ranging from not drinking tea to getting a hysterectomy (which was done, in her mid 40s). It turned out she wasn’t absorbing iron due to Celiac disease. Treating the anemia as if it was an isolated condition wasn’t helpful at all since she needed to address the root cause, Celiac.

[haldujai]

“Anemia” isn’t really a diagnosis.

Your mother had a microcytic anemia (a broad class based on lab results), of which there are several types including iron deficiency anemia.

Next, there are multiple causes of iron deficiency anemia of which celiac disease is one of them.

You would never diagnose a patient with “anemia” and stop there. Further work up for the etiology is mandatory and endoscopy is commonly performed.

There is no such thing in modern medicine as “just treating anemia” unless you know the cause and the only treatment is transfusions.

[code_duck]

I would imagine that more details were available, but I’m recounting some thing that happened to someone else 30 years ago when I was a teenager. So I’m not really clear on the precise details. All I know is that they said she was low on iron and anemic, and the suggestions were to not drink tea and they gave her a hysterectomy. As noted, they failed to discern the actual cause at that time. She was diagnosed with celiac about 10 years later.

[danachow]

This is a good learning/discussion point: The post common cause of iron deficiency anemia in menstruating females is menorrhagia. Celiac disease is often an acquired disease in later adult hood.

This is not to comment or challenge directly your case but knowing the two above facts it is not uncommon (in fact I have personally seen this in practice) where your above outline is perfectly reasonable.

A woman may have multiple reasons or a sequence of reasons for IDA, developing celiac later in adulthood - it’s totally possible they had chronic blood loss anemia before that.

[DangitBobby]

> You would never diagnose a patient with “anemia” and stop there.

I kind of doubt that. In my experience, the treatment for chronic heartburn is to throw meds at it to stop the symptoms. After an upper endoscopy, no attempt at root cause was ever made.

[haldujai]

As much as you doubt that based on your anecdotal experience (addressed below), I’ve respectfully spent the past 9 years practicing medicine in 16 different hospitals across three countries and feel I am in a more appropriate position to comment on the medical standard of care.

I can say with absolute confidence at none of the places I’ve worked at would a doctor leave a patient with a diagnosis of anemia as this is malpractice. Are there physicians in some hospitals who practice negligently?

Sure, but there are also pilots who show up drunk to work and engineers who are negligent. That doesn’t mean the entire profession has a “problem”.

Anemia is not heartburn. Anemia can be life threatening.

As an analogy for the tech world. Anemia is a server crash. Heartburn is a warning in the server logs.

You may decide the warning is not worth fixing / may result in new bugs (aka complication).

When a server crashes step 1 is to get it back online (transfuse to a safe hemoglobin target).

Step 2 is find out why the server crashed (why is this patient anemic, which is a sign/symptom and not a diagnosis).

Just as a computer engineer would never say “I’m not sure why but let’s just keep restarting every time it crashes”, a doctor would not say “I’m not sure why you’re anemic” unless there was an extensive negative workup and the patient normalized therefore no longer requiring treatment.

There is no situation where a physician just keeps transfusing an anemic patient without figuring out why. This is not only expensive, but transfusions carry risks and with repeated transfusions some risks increase. This is not a medically accepted management plan anywhere and the hospital / blood bank would quickly intervene if a non-hematologist was serially transfusing a patient as this is outside their scope.

In your example:

Your negative endoscopy excluded H. pylori, gastric malignancy, peptic ulcer disease, and a hiatal hernia. Those are all of the easily treatable and life threatening conditions we should not miss.

Your next options for investigation would be a 24 hour pH study with consideration for fundoplication. This is a major surgery with risks and complications that are believed to be worse than PPI therapy.

Patients who fail PPI, are unable to be weaned, or have contraindications are the ideal candidates for such an invasive procedure. You don’t want to send every heartburn patient to fundoplication, we used to do that and made a lot of people worse.

[code_duck]

I feel that patients are qualified to comment on medical standards of care, also.

I am sure that you’re a good doctor, but to answer your question, yes, there are many doctors who operate negligently, to some extent. I had a long experience at one of the major hospitals in the US following drastic weight loss and months of pain. A major hospital did various tests, and ended up telling me I had “health anxiety”. It turned out that I was actually developing LADA, a form of type 1 diabetes. Since I had already been diagnosed with celiac and was having primarily digestive symptoms, the tests they did focused on the digestive tract and they never investigated other causes. I had to finally go into diabetic ketoacidosis before anyone figured it out.

[haldujai]

Unfortunately you are confusing “medical standard of care” with the “standards of medical care”.

“The most common legal definition of standard of care is how similarly qualified practitioners would have managed the patient’s care under the same or similar circumstances. This is not simply what the majority of practitioners would have done.”

Source: https://biotech.law.lsu.edu/map/StandardofCare.html

As you can see, patients are not qualified to comment on the medical standard of care and unfortunately how you “feel” isn’t a consideration in the decision as this is established in case law.

To your larger point, if you are dealing with a negligent doctor the place to address it is at a medical licensing board. With a single paragraph complaint they will gut a doctor for diagnosing anyone with “anemia”.

Instead of spreading partially misremembered stories online and spreading vitriol I suggest you use the many, free channels available for recourse if you feel your doctors actions constitute malpractice.

I appreciate these things can all sound similar and be confusing. Perhaps best to leave to the professionals dedicating 10+ years to learning the trade.

[danachow]

How would you have done your diagnostic workup differently than what was done - specifically?

What was the negligence what was the diagnostic smoking gun that was missed?

> I feel that patients are qualified to comment on medical standards of care, also.

Patients like doctors is a huge group that should not be generalized - but health and healthcare literacy is pretty bad so by and large, no, patients can comment on standards of care but they aren’t qualified to do so.

[DantesKite]

> If your wife had hemoglobin that low, then she was correctly diagnosed with anemia.

That seems like a somewhat myopic perspective.

Saying this patient was "correctly diagnosed with anemia" would be like diagnosing a cancer patient currently undergoing chemotherapy with male pattern baldness.

A more accurate and helpful diagnosis would probably be something like "Babesiosis"——anemia caused by ticks infected with a microbe that destroys red blood cells especially considering the multiple cofactors at play. Or whatever it was that specifically caused the anemia; the parent comment didn't say.

[danachow]

Dude, I'm just addressing this: "So things that can look like anemia can be other things! Case in point, my wife was misdiagnosed for months with Anemia."

Which is a bit of a confused statement.

> Saying this patient was "correctly diagnosed with anemia" would be like diagnosing a cancer patient currently undergoing chemotherapy with male pattern baldness.

No, that's a pretty shit analogy and completely wrong. First, because chemotherapy doesn't cause "male pattern baldness" - the mechanisms aren't the same. So that's just wrong - while someone with a hemoglobin of 4 has anemia, whatever the underlying cause may be - it isn't a look alike - it is.

Second, diagnosing Alopecia (secondary to chemotherapy) is a perfectly reasonable diagnosis. Because it is something that doctors do manage with specific things separately from the chemotherapy and other cancer treatment, eg wigs, scalp cooling.

People can have more than one relevant diagnosis that they are treated for and are interrelated. For instance, if someone has anemia that is due to something like a GI bleed, they have both a GI bleed and anemia. If their hemoglobin is less than 7 you will likely treat that anemia with a blood transfusion independent of what you're doing to manage the GI bleed. GI bleed, iron deficiency, malabsorption, microcytic anemia are all diagnoses - they may be all interrelated.

> A more accurate and helpful diagnosis would probably be something like "Babesiosis"--anemia caused by ticks

But babesiosis is not anemia. It often occurs with it, but the diagnostic criteria for babesiosis is blood smear or PCR. If someone has a smear positive for babesia then they have babesiosis regardless of their Hgb/Hct.

And notably they listed a bunch of tick borne illnesses listed, babesiosis was not among them.

[medymed]

Right idea generally but in that scenario it would be like making a diagnosis of alopecia which just means hair loss. In any case some diagnoses don’t have clear explanations or subdivisions for decades or centuries until explanatory medical science catches up with the descriptive diagnoses like anemia or alopecia.