I'm going to teach you a secret of medical practice, folks. We don't always know what's wrong with you. And - here's the kicker: we don't always have to.
When you come in with a symptom - let's say it's abdominal pain - I don't need to know if it's a muscle strain or a virus. What I need to know is whether it will kill you (or your fetus) and/or whether it will get better on its own (we say "resolve"). That's really it. If the answers are NO/YES, then you get to go home.
We spend a LOT of time and money proving the NO/YES. With that abdominal pain, depending on your medical history and age and other circumstances, you may get a pregnancy test and a CT scan and a few blood tests and an ultrasound and an uncomfortable rectal exam. And in the end, you'll be sent home with a long list of things you don't have: an ectopic pregnancy, a twisted ovarian cyst, an appendicitis, bleeding from your intestines, gallstones. You'll get some pain medicine, you go home.
And you may get a diagnosis like this: "gastroenteritis". That is a long word that basically means: A Virus. And as I explained to my husband (the Bearded Economist) long ago when I was a medical student: we don't (usually) really know if you have A Virus. What we are saying when we tell you it's A Virus is : this won't kill you, and it will probably get better on its own. That is, NO/YES.
In my experience, this is the most true of high-acuity-outpatient-type medicine, such as what happens in the Emergency Department, or in OB Triage, where the focus is on trying to decide whether this is, in fact, an emergency.
In the regular office, you spend a lot of time on the NO/NOs. That is, things that won't kill you (like vaginal discharge, or lower back pain, or ear infections) but won't get better on their own. And those things are important - they really, really are - but they are not emergent, and because of that, you can often take the time to see where they are going; you can send one test, wait for it to come back, try one thing, see if the patient gets better and go from there.
In the emergent/acute care settings, there isn't that luxury. The patient is there because you may (or may not) have an emergency (which we can define, often, as a YES/NO). Also, they're going to leave; you only have this one visit to figure out what's going on. So we try to figure it out and get to that NO/YES.
Clearly this is a simplistic model of acute-care diagnosis. Oh, please do not think I'm a bad doctor - I spend a LOT of time trying to figure out what's going on with my patients, and not just kicking them out of triage after I decide it's nothing. In fact, it's because of this that I have a hard time sending anyone out, and always give them a long-and-folksy speech about coming back if anything changes (more on that in another post). But I thought of it as a model, and thus limited and simplified, but still useful.
What's interesting about this kind of thinking - the NO/YES goal - is that it costs lots of money, and lots of anxiety (both patient and doctor). And it's really difficult on everyone involved, because the limits of your NO/YES are really the limits of your imagination: Is there anything I haven't ruled out that would kill this patient, or get worse? Are there any diagnoses anywhere in the world of medicine that would make this a YES/NO?
And so you can see how this could be a difficult and roundabout way to get to a diagnosis or to any sort of reassurance. And how it creates every incentive to damn the torpedoes and send another test and another and another.
This was going to be a longer post about anxiety, and what I think would revolutionize the American health care system (is it just me, or do my posts get more and more grandiose as time goes by)? But I'm tired, and also will be totally embarrassed if I fail my boards, so that will have to keep for next time.
I love the whole "virus" thing. It is one of the most useful and useless terms but most patients feel much more satisfied when you tell them "virus" than when you say "i have to idea but it doesn't look bad" There are so many other relatively meanigless terms we throw around. One of my favorites is a "pinched nerve" since that's my business. People come to me having been told by somebody at some point that they have this and they are usually very attached to this diagnosis. It is usually accompanied by an MRI that shows some disks a little off center because almost everybody in the whole world has those. Sometimes they actually turn out to have a pinched nerve but it can also turn out to be MS or parkinson's disease or carpal tunnel or migrane or just nothing much. I try to recorgnize all the former possibilities. However, it's that latest possibility that causes the most trouble and is probably the most common. It's a NO/Maybe. Nobody likes that, especially not me because it doesn't make me sound like I know anything.
ReplyDeleteA friend of mine, having felt like crap for quite a while, went to her doctor. He told her that there was "no evidence of any illness." He would have done much better to see the ample empirical evidence of something-or-other and diagnose her with a virus or pinched nerve!
ReplyDeleteIn the lay person version of medical lore (and in the TV version too), doctors are supposed to be able to tell you what's wrong when you feel bad (and then, at least on House, which is actually my only experience of medical TV, the problem is supposed to be extremely rare and hard to diagnose and then typically quite easy to fix and send the patient home in an entertaining 48 minutes). Anyway, it seems to make sense that just telling you what's NOT wrong can fall a bit flat -- it's not the answer per se that's disappointing, it's the expectation of an answer that's perhaps mismatched between patients and doctors...
ReplyDeleteI think there was a relatively recent piece in the NYT Magazine on how much doctors spend on proving that their patients are not in danger, even when they already know this to be true? (Or are 99% sure it's true). The writer blames the fear of malpractice for huge sums of wasted $, using the teenage patient's father's loud threats to illustrate the case. I found it very compelling.
ReplyDeletePlease post on FB when you have a new posting so I won't miss any!
Love the blog.
Rena
I'm also a big fan of "idiopathic." And I give extra good-doctor points to someone who says that, and then gives me the 'wry, hey, I'm doing my best here, but bodies are wierd' expression.
ReplyDeleteBecause, holy moly, so they be.