How often is the Doctor Wrong?

Wrong is a strong term. The way we look at appendicitis is that there are risks to having untreated appendicitis - rupture, peritonitis, sepsis, and death - and there are risks to treating appendicitis - the risks of surgery (see the exhibit "Results of appendectomy") Overall, our ability to diagnose appendicitis prior to rupture has limits - we can find appendicitis with scoring systems, diagnostic tests, and X-rays about 96% of the time. An old professor of mine used to say "any idiot can diagnose a ruptured appendix."

Since we have reduced the risk of surgery to significantly less than the risk of a ruptured appendix (unless you are having your appendix out at a teaching hospital - see "Some thoughts on Complications…") t is appropriate to have the appendix be "normal" about 4% of the time. And even at that, patients who have an appendectomy and whose appendix is normal appearing, and even normal pathologically, will frequently emerge from anesthesia cured of the pain and symptoms thatled to the diagnosis of appendicitis in the first place. So a "normal" appendix doesn't mean the doctor was "wrong." It simply means that the calculation of risk versus benefit for the presenting symptoms favored surgery over observation.

Now, the other side of "wrong." You came in, you were evaluated and you were sent home, only to come back sicker a day later and found to have a ruptured appendix. Again, there are limits to our ability to diagnose appendicitis. We get it about 96% of the time. The discussion with a patient in whom we do not believe that surgery was indicated and later found a ruptured appendix means that we were wrong. We review these cases quite thoroughly afterwards. Generally the evidence at first presentation was equivocal, an Alvarado score of 5, say. If a CT scan was done, the appendicitis may have been too early to see. Frequently, no imaging was done. And there is almost always a good reason for not imaging, usually a desire to avoid radiation exposure.