The Minestrone Soup Talk
Patients will sometimes ask, “How do you know I have lupus?” One response is the “minestrone soup talk,” the essence of which is:
“The diagnosis of lupus is similar to the diagnosis of minestrone soup. No single ingredient or combination of ingredients will confirm or exclude the diagnosis of either lupus or minestrone soup. Each has many variations. However, no matter how minestrone presents, it is never confused with clam chowder.”
When you label a patient with a specific diagnosis, it should have both therapeutic and prognostic implications. Many syndromes encountered in the practice of rheumatology remain “unclassifiable” even over a prolonged period of follow-up. Over two decades ago, I prospectively reviewed the records of 200 consecutive new patients seen in my practice.3
Eighteen (9%) patients in this group were unclassifiable at the time of initial presentation despite objective evidence of a disorder. All patients had at least one physical finding characteristic of a systemic rheumatic disease (synovitis in 16 and rash in two patients), but otherwise did not meet criteria for a specific diagnosis by accepted standards. They were categorized as having an “unclassifiable systemic rheumatic disease.” All but one patient, who was lost to follow-up at five years, were followed for nine years, at which time the data were analyzed. A specific diagnosis evolved in only two patients (psoriatic arthritis and rheumatoid arthritis with interstitial lung disease). Four patients underwent a complete spontaneous remission. The remaining 11 patients did not evolve into a specific diagnosis by accepted classification criteria despite the prolonged period of follow-up. Nine patients improved with treatment, one deteriorated, and another died with interstitial lung disease.
Such patients are seldom reported in the literature, yet they were among the five most common diagnoses seen on both initial and follow-up visits in my practice.
The greatest body of medical knowledge is based on conditions that don’t get better. Many conditions we only observe and don’t understand. Dealing with uncertainty is a common experience in the practice of medicine and particularly in rheumatology. It often creates a sense of humility, which in itself can be enriching. Although, to the best of your knowledge, you may never have seen a case of the condition you are confronted with, it is probable that, sometime in the past, the condition has seen you.
Never be afraid to tell a patient you don’t know something. It may be a challenge to then convince them they are seeing the right doctor, but it can be done and is the most honest course to follow.
