William Cayley: To doctor is to diagnose

bill_cayley_2I appreciated Richard Smith’s recent discussion of mental models—too often, I think, we simply carry on with practice as usual (or, “life as usual”) without sufficient critical attention to the paradigms on which we rely to organize our thinking and doing.

I would beg to differ with him, however, on the argument that “diagnosis is no longer important because most patients have long term conditions.” To the contrary, it is precisely because our patients have (often multiple) long term conditions that diagnosis has become even more important.

The more conditions our patients have, and the more tests we have to run on them, the more the risk increases of premature closure in diagnostic thinking, or over-reliance on data points and not the patient’s story. Time and time again, I’ve seen a patient who sought emergency care for chest pain, and was either admitted for “a cardiac issue” because of one lab test outside normal parameters (without a clear sense of the actual clinical problem or question), or was discharged home with the advice that “you don’t have a heart attack, go see your primary care doctor.”

That is not practicing medicine—that is ticking a checklist. When our patients have a “complaint” (or “concern,” depending on how you want to phrase it), we need to work with them and care for them to see them through whatever is going on. Modern medicine has given us many tools and tests, but it has also led to over-reliance on tests to the neglect of listening to the patient’s story—and when we focus mainly on the tests, we are satisfied when they look “normal” without attending to whether or not the patient has been cared for.

Going back to the chest pain illustration, when a patient presents for care with chest pain, he or she doesn’t just want to know that “your numbers are OK,” he or she most likely wants to know what is going on and what it means for the future. Sorting that out requires adequate diagnosis, and it requires sticking with the patient through the uncertainties of not yet having a diagnosis, in order to work towards finding out what is truly going on.

I appreciate what Dr Smith’s friend told him: “I go weeks without a diagnosis.” One of the fundamental lessons of learning to practice primary care is learning to live and work with uncertainty, both being comfortable ourselves with diagnostic uncertainty, and walking with our patients through prognostic uncertainty. Bazemore and colleagues recently published some intriguing data, which documented a correlation between increased comprehensiveness of care by family physicians and decreased costs and rates of hospitalization. To me, this suggests that having a primary physician who will stick with you, and who will give you continuity of care through the uncertainty of not yet having a diagnosis, may actually be better for you.

Fundamentally, however, this process of giving continuity of care, and walking with our patients through the uncertainty of “un-diagnosis,” must be in the context of working—thoughtfully—towards arriving at a diagnosis.

Much of “modern” chronic care may be working with our patients to help them manage their known conditions, but when our patients are sick—perhaps with confusing symptoms potentially attributable to multiple interacting biological, psychological, or social factors—they look to us to help them find the best diagnosis in order to be able to move on with life.

Medicine may never have been as simple as “diagnose, treat, and cure”—I’m not sure we were ever as successful as we’d like to think at being able to simply “treat” and “cure.” Another long standing aphorism in medicine has been: “To cure sometimes, to relieve often, to comfort always.” An important part of caring is doing our best at helping patients understand not only what “is” right now, but “what is to come” in the future.

Maybe the aphorism for today’s medicine should be: “Diagnose, Prognose, Care.”

William E Cayley Jr practices at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.

I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.