Treating Patients Without A Diagnosis

Masked Doctor

Doctor, what's wrong with me? 

By Kevin RR Williams

HEALTH I remember, some years ago, sitting with a relative across a large wooden desk in a doctor's private office. We discussed symptoms for half an hour during an initial consultation. On a different occasion, I recall another doctor pinning an MRI on the wall, circling an area and articulating exactly why the radiologist overlooked a diagnosis. There was a doctor who stood bedside, outlining what was known, what was baffling and how it would be investigated. Back in those days, there were even phone calls from physicians with results. Does this sound like an episode of Royal Pains?

Entertaining Good Physicians

Perhaps entertainment has altered our perception of medical reality. Some of the most popular television shows have invited viewers behind the scenes of hospitals — notably, House MD and E.R. In different ways, television may have elevated our perception of doctors' ability to quickly diagnose and treat diseases. By demystifying the most perplexing ailments within the span of an hour, all "good physicians" are equated with capable diagnosticians.

Rightly or not, as a patient, when I visit the doctor, I am lulled into the notion that I deserve, even must have, one of these good physicians. In the absence of an astute diagnosis prior to treatment, my physician must be the contrary. This makes me long for the foregone days when doctors cared about patients, when they treated the whole person, not just the symptoms. But wait. Do I actually recall such a historical time or are these vignettes just figments of my entertainment-filled imagination?

What's Missing From Abundance of Care?

Over the past couple of decades a different pattern has emerged. With rising health costs and more patients in the waiting room, many physicians have been constrained to delegation, referral and pre-diagnostic prescription for non-life-threatening conditions. Visits to primary care physicians feel more like a triage. Patients are moved through exam rooms with efficiency and dispatch. Even if doctors wish to spend more time with a patient, the overcrowded waiting room dictates otherwise.

I can't quite accuse doctors of carelessness. Brain tumors are ruled out with an MRI in response to headaches. If a patient presents numbness, a team of cardiologists, neurologists and physical therapists receive referrals with plenty of blood draws and lab tests. All this activity provides a chimera of care. Insurance companies and patients with high deductibles see plenty of billable services. So what's missing? A diagnosis.

Prescription In Lieu of Diagnosis

Prescription in lieu of accurate diagnosis is becoming commonplace. There are certain prescriptionable buzzwords requiring little patient explanation. Skin eruption? Eczema. Aches and pains? Non-specific inflammation (or myalgia). To be fair, many patients present ailments for which proper diet and exercise is the remedy. Since doctors can only advise but not administer these, treating symptoms keeps complaints down.

Under the nom de plume Angry Orthopod, MD, a physician weighs in on the growing lack of diagnosis. "Our over-testing can place the patient in harms way… There are only three results that can come from any medical study or test. You might find what you are looking for, find nothing (negative/normal result), or a result that is unexpected." This doctor feels that fellow physicians should, from patient evaluation and history, be able to diagnose ailments before lab tests, which are used to confirm, not fish for a diagnosis. Orthopod continues, "Let me say with pure clarity, it is my job to interpret and clinically correlate any and all findings.… It is a bit of a lost art in my opinion." [1]

Gastroenterologist Michael Kirsch, MD posits, "Would you rather your physician be an astute diagnostician or a compassionate and empathic practitioner?" Who said, "Both?" Kirsch concludes, "Doctoring is tricky business, and we don’t know the specific ingredients and proportions that constitute a great physician. There is no recipe. It's an amorphous mixture of humanity, humility, medical knowledge, clinical experience, excellent communication skills, compassion and personal warmth." [2]

In Search of A Lost Art

"Lost art" and "tricky business?" How could that be? These are doctors who have spent years in schools, have served a residency in teaching hospitals and earned walls full of degrees. Quiet is kept. Most doctors are not diagnosticians. In fact, this is a specialized field of medicine. Technically, an internist is supposed to fill this roll. He is like a general contractor in a construction project — the key person responsible for the work of many specialists. But lately, it seems more specialists are being involved prior to obtaining a thorough history.

A medical specialty may be as narrow as bones of the hand or Ménière's disease. Referred patients are either ruled out or forced into a doctor's individual field of expertise. There is no inclination to diagnose otherwise. So comprehensive diagnosticians are rare. And since internists are routinely paid less than specialists, new medical students are opting for the higher-paying specialty professions. This is minimizing the chance of a future fix.

Dr. Steven Knope, author of Concierge Medicine: A New System To Get The Best Healthcare observes, "The hospital where I practice has over 700 doctors on staff. The fact that only 9 of us still take care of our own patients when they are hospitalized answered the question about internal medicine's future. It is no longer an issue of whether traditional internal medicine can survive; the facts are – at least outside of the concierge model – internal medicine is already dead." [3]

So there is a very real shortage of diagnosticians. The ones who remain are attempting to pick up the slack but are overloaded. This problem is seen in many branches of medicine. "I believe that not only can psychiatrists provide better care than the medication-laden treatments we dole out today, but we have a responsibility to do so," says Steve Bolt, MD. [4]

Idiopathic Diagnosis is an Oxymoron

If, as a patient, I notice a procedural change and doctors themselves see it too, it must not be fed by an entertainment-filled imagination. The healthcare business has undergone a radical service decline. And many are losing their patience.

When an unexpected pain arises under the current healthcare model, I anticipate, following an 8-minute consult, lab work to rule out major things like an excisable mass or cracked skull. If results are negative, I am prescribed a pain reliever and shouldn't concern myself with the whys and wherefores. The "diagnosis" is bound to be "idiopathic" or worse yet, one that will later be rescinded.

There appears to be a real shortage of diagnosticians. Overloaded internists are attempting to pick up the slack but the declining level of care is apparent. What about you? Are you more concerned with why a particular illness developed or just how to relieve it? [5,6]

Continue reading Is Concierge Medicine Your Answer to Impersonal Healthcare?

Tags: effects from shortage of doctors, has the medical practice changed, improving

  1. A good doctor should rarely be surprised by test results. ^
  2. Choose your doctor: Astute diagnostician or empathic practitioner? ^
  3. Is traditional internal medicine dead? ^
  4. "We're Doctors. We Prescribe Drugs. That's What We Do." ^
  5. Nurse practitioners, doctors, and the lost art of diagnosis ^
  6. Has Entertainment Altered Our Desire For Diagnosis? ^

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