Tuesday, June 05, 2007

Twenty Questions

I while ago, I had a friend show me this little electronic ball called "20 Questions" that promised to guess what I was thinking with only twenty questions. I thought a bit, decided on an inanimate object for the gizmo to guess, and then answered the questions one by one that the device posed to me. For each question I pushed the buttons corresponding to "Yes,"No," "Sometimes," and "Unknown" in response. I was astonished at the depth of answers the device could conceive based on my answers, but soon realized I could "beat" it by thinking about something fairly obscure or unusual.

Now it seems "20 questions" has come to diagnostic medicine.

iVillage.com has introduced a beta version of its "Symptom Solver" in conjunction with GE Healthcare that helps patients determine possible causes for the symptoms they are experiencing. It seems that medicine can really be reduced to 20 questions!

So I decided to take the system for a test drive.

My case?

I pretended to be a 24 year-old 34-week pregnant woman who has had two hours of chest pain associated with abdominal cramping from a dissection of a coronary artery with an associated heart attack that also induced labor (I had a case like this). This was on the Women's Wellness section of their website after all... Let's see how it does....

First question: My age? 18-29. Check.

Second question: Which symptoms (about 20 were shown)? I clicked on "Abdominal pain or discomfort" and "Chest Pain." Check.

Third question: "Tell us more about your abdominal pain?" I clicked "Abdominal Pain extends to the back and other areas." Check.

Fourth question: "Tell us more about your chest pain?" I clicked "Chest pain extends to arms, shoulders, neck, back or jaw" and "Chest pain for longer than 20 minutes." Check.

With the next screen, I received an "Emergency Notification" in small red letters at the top of the question box suggesting I seek immediate medical attention for my chest pain extending to my arms, shoulders, neck and jaw and chest pain for over 20 minutes. But I ignored this and continued... after all I'm only 24 years old!

Fifth question: "Additional symptoms?" I checked "Chest tightness," "Abdominal tenderness," "Sudden sharp chest pain," and "Heartburn." Check.

The next screen gave be my most likely diagnoses so far in the following order: (1) collapsed lung, (2) gastroesophageal reflux (What's that, I wonder as a non-medical person?), (3) pancreatitis (huh?), (4) cardiac ischemia (sounds interesting...but they expect me to know what this is?, and (5) heart attack (I know what that is, only old people have one of those...). Oh, and this little disclaimer appears:
The Symptom Solver service is designed for educational purposes only. You should not rely on this information as a substitute for personal medical attention, diagnosis or hands-on treatment. If you are concerned about your health, please consult your family’s health provider or go to the emergency room.
So I answer the next question:

Sixth question: "Tell us more about your heartburn?" I click "Frequent heartburn." Check. (Hey, things must be better! That little red warning box went away...)

With the next screen, GE reflux springs to the top of the likely diagnoses! Whew! I'm feeling reassured already! Glad it's not my lung! So I continue...

Seventh question: "Select additional symptoms:" I checked "indigestion." Check.

Eighth question: "Select additional symptoms:" I checked "Cramps" here. Check.

Of course, it wants to know more about the cramps. I noticed now the diagnosis of Irritable Bowel Syndrome is now in the mix of possibilities. (Hello, would anyone think about pregnancy??? But maybe the "Symptom Solver" needs more information...)

Ninth question: "Tell us more about the cramps:" I checked "Abdominal cramps" and "Sudden, severe abdominal cramps." Check.

Tenth question: "Additional symptoms?" This time I didn't see anything that correlated, so I said "None of these. Show me more." (Ugh... Hmmm, I'm feeling this sudden incredible sense I need to have a bowel movement...)

Eleventh question: "Select additional symptoms:" Hmmmm. My eyes don't look yellow, I'm not dehydrated (am I?), my heart is not pounding... I just have to have a bowel movement. So once again I click "None of these. Show me more."

The next screen got closer when it again asked for additional symptoms:

Twelveth question: "Select additional symptoms:" Oh my goodness! Although I feel like I needed to have a "bulky or foul-smelling stool" but I hadn't had this yet, so I again checked "None of these. Show me more." By now, I'm becoming weary...but I persist!

This time some interesting things popped up to select:

Thirteenth question: "Select additonal symptoms:" I checked "Loss of interest in sex" and "bloating." Check. (By the way, I have been at this for an hour now. It seems the website loads its ads too slowly...) Wow, that chest pain sure is burning... The order of diagnoses right now? #1: Gastroesophageal Reflux, #2 Collapsed Lung, #3 Heart Attack, #4 Irritable Bowel Syndrome, #5 Pancreatitis.

Fourteenth question: "Select additional symptoms:" Hey look, there's "Pregnancy!" So I click it!

Sadly. I'm asked again to select an "Additional Symptoms:" So for Question Fifteen, I answer "Pain all over."

Question sixteen appears: "More symptoms!" So I pick "Lump or mass in the pelvis or abdominal area."

Again, adding more symptoms is what is needed it seems: But for question seventeen's questions, I pick "None of these. Show me more." (I'm feel a bit masochistic now...) And now, my top five diagnoses do not include heart disease: #1 Gastroesophageal reflux, #2 Irritable Bowel syndrome, #3 Esophagitis, #4 Ovarian Cancer, #5 Collapsed Lung. And yes, it wants more symptoms for question seventeen.

Question seventeen: More symptoms: I pick "Severe lower abdominal pain or pelvic pain."

And again: It wants more symptoms but I've run out. 10 more answers to the additional symptoms questions with "None of these. Show me more." makes clear that the program will continue to ask symptoms until the person clicks "Skip to Results." At which time I see an explantation of Gastroesophageal reflux disease, Esophagitis, Irritable bowel syndrome, Collapsed Lung, Ovarian Cancer, Misscarriage, Stomach Cancer, an then finally, Heart Attack (#8).

I think I beat the game, but probably sacrificed my fictional heart and baby...

What is clear is that more and more of these tools will soon surface on the internet, especially with similar efforts underway by Steve Case, former co-founder of AOL (RevolutionHealth), or by other corporate efforts like the Continua Health Alliance. It is clear that patients are turning to the internet more frequently to identify a cause of ailments before seeking the advice of a health care professional. While there is great information out there, there is a moral to today's post:

Take these symptom-related questionnaires with a grain of salt... you might just beat them at your expense.



Anonymous said...

That's right Wes and soon your "I don't make enough money to do that test" attitude is going to get run over by more informed patients that will know about your the other MD down the street that does offer the MTWA test.

Margaret Polaneczky, MD (aka TBTAM) said...

Great post - I would have given up after the fourth question...

How did the real life patient do?

Anonymous said...

Guess you don't have to quit your day job just yet!

DrWes said...


She and her baby did fine, fortunately. She sought ER evaluation immediately and was treated w/POBA (plain old balloon angioplasty) to tack up her dissection of her right coronary artery, treated with heparin and beta-blockers, carried her baby to term, and had an uneventful delivery (no c-section).


scalpel said...

Wow, I feel so unnecessary now. That program is pretty good.

KC Saul said...

According to the machine, I have pancreatitis, pericarditis, diverticulitus, irritable bowel syndrome or ovarian cysts. It doesn't localize the pain by quadrant or it could have ruled out the ovarian cysts. That's another condition I don't go to the ER when I'm having pain from. It cheats and asks if you have a history of gallstones or pancreatitis and all of that, but I had to say No (since my gallbladder was removed years ago).

Doctors don't have to quit their day job.

Lisa said...

I'm a 36 yo female w/Cushing's Disease, well I just had that pesky tumor out 14 days ago actually, so I felt qualified to take those 20 questions out for a test drive. ;)
I'll bold what didn't get a checkmark.

Abdominal pain or discomfort [secondary addisons, yes], Anxiety [still have some, but thyroid meds help a lot], Back pain [secondary addisions, yes], Chest pain [frequently], Confusion or disorientation [well, only if I have an adrenal crisis], Coughing [no, tg!], Dental pain [Cushing's will make your teeth fall out, yes], Diarrhea or constipation [Have you ever taken morphine on top of fentanyl? Check.], Difficulty breathing or shortness of breath [take three steps, check], Dizziness or spinning sensation (vertigo) [secondary addisons, it can happen but not usually], Fast or irregular heartbeat or pulse [egads, all the freakin' time], Fatigue, weakness or exhaustion [constant], Fever [secondary hypothyroidism, my fevers are normal human temp], General ill feeling [check!], Headache [3+ years, constant], Joint pain [osteoarthritis, I need a new rt shoulder at 36!], Muscle aches or pains [check.], Nausea [SA, check], vomiting or dry heaves [if I get that far, get me a needle quick],
Numbness [part of having carpal tunnel, non?], Skin rash [only if anything touches it], Swelling [still +1 to +2 pitting on my legs!], Vision problems or changes [double vision, monocular].

The best it could do was:

1. Chronic Fatigue Syndrome - I'd make a really good blind-in-my-left-eye fatigue patient wouldn't I?? *choking iVillage with my 1cm pit tumor that was pressing on my optic nerve*

other dx: 2. Pre-eclampsia [I guess that tubal didn't take after all! Yikes!] 3. Endocarditis 4. Sickle Cell Anemia [I'm not positive, but my pure Dutch grandmother & father would probably crap themselves if I told them I had SCA.]

I'm all for a patient having good access to quality information. I'd hate to think someone would log on to this symptom analyzer and not take what it said with a grain, or pound, of salt.


Google still rocks the casbah when it comes down to it.

DrWes said...

"Sickle Cell Anemia [I'm not positive, but my pure Dutch grandmother & father would probably crap themselves if I told them I had SCA."

Nearly dropped my coffee this morning while laughing, Lisa. Thanks for your insights.

Anonymous said...

It totally failed to diagnose Buerger's disease. Good thing it's non-emergent.

KC Saul said...

Questions the program needs to add to itself:

Did you just try a brand-new exercise that involved the oblique muscles?

Was your martial arts instructor feeling particularly sadistic that fine Saturday morning?

Did you have to do fifty of them on each side?

Results: You got yourself a boo-boo