{"id":34447,"date":"2015-06-16T15:52:00","date_gmt":"2015-06-16T14:52:00","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=34447"},"modified":"2015-09-22T14:23:40","modified_gmt":"2015-09-22T13:23:40","slug":"william-cayley-to-doctor-is-to-diagnose","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2015\/06\/16\/william-cayley-to-doctor-is-to-diagnose\/","title":{"rendered":"William Cayley: To doctor is to diagnose"},"content":{"rendered":"

\"bill_cayley_2\"<\/a>I appreciated Richard Smith\u2019s recent discussion of mental models<\/a>\u2014too often, I think, we simply carry on with practice as usual (or, \u201clife as usual\u201d) without sufficient critical attention to the paradigms on which we rely to organize our thinking and doing.<\/p>\n

I would beg to differ with him, however, on the argument that \u201cdiagnosis is no longer important because most patients have long term conditions.\u201d To the contrary, it is precisely because our patients have (often multiple) long term conditions that diagnosis has become even more important.<\/p>\n

The more conditions our patients have, and the more tests we have to run on them, the more the risk increases of premature closure<\/a> in diagnostic thinking, or over-reliance on data points and not the patient\u2019s story. Time and time again, I\u2019ve seen a patient who sought emergency care for chest pain, and was either admitted for \u201ca cardiac issue\u201d 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 \u201cyou don\u2019t have a heart attack, go see your primary care doctor.\u201d<\/p>\n

That is not practicing medicine\u2014that is ticking a checklist. When our patients have a \u201ccomplaint\u201d (or \u201cconcern,\u201d 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\u2019s story\u2014and when we focus mainly on the tests, we are satisfied when they look \u201cnormal\u201d without attending to whether or not the patient has been cared for.<\/p>\n

Going back to the chest pain illustration, when a patient presents for care with chest pain, he or she doesn\u2019t just want to know that \u201cyour numbers are OK,\u201d 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.<\/p>\n

I appreciate what Dr Smith\u2019s friend told him: \u201cI go weeks without a diagnosis.\u201d 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<\/a> 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.<\/p>\n

Fundamentally, however, this process of giving continuity of care, and walking with our patients through the uncertainty of \u201cun-diagnosis,\u201d must be in the context of working\u2014thoughtfully\u2014towards arriving at a diagnosis.<\/p>\n

Much of \u201cmodern\u201d chronic care may be working with our patients to help them manage their known conditions, but when our patients are sick\u2014perhaps with confusing symptoms potentially attributable to multiple interacting biological, psychological, or social factors\u2014they look to us to help them find the best diagnosis in order to be able to move on with life.<\/p>\n

Medicine may never have been as simple as \u201cdiagnose, treat, and cure\u201d\u2014I\u2019m not sure we were ever as successful as we\u2019d like to think at being able to simply \u201ctreat\u201d and \u201ccure.\u201d Another long standing aphorism in medicine has been<\/a>: \u201cTo cure sometimes, to relieve often, to comfort always.\u201d An important part of caring is doing our best at helping patients understand not only what \u201cis\u201d right now, but \u201cwhat is to come\u201d in the future.<\/p>\n

Maybe the aphorism for today\u2019s medicine should be: \u201cDiagnose, Prognose, Care.\u201d<\/p>\n

William E Cayley Jr<\/strong>\u00a0practices\u00a0at 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.<\/em><\/p>\n

I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.<\/p>\n","protected":false},"excerpt":{"rendered":"

I appreciated Richard Smith\u2019s recent discussion of mental models\u2014too often, I think, we simply carry on with practice as usual (or, \u201clife as usual\u201d) without sufficient critical attention to the […]<\/p>\n

More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1357,14769],"tags":[],"class_list":["post-34447","post","type-post","status-publish","format-standard","hentry","category-us-health-care","category-william-cayley"],"yoast_head":"\nWilliam Cayley: To doctor is to diagnose - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2015\/06\/16\/william-cayley-to-doctor-is-to-diagnose\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"William Cayley: To doctor is to diagnose - The BMJ\" \/>\n<meta property=\"og:description\" content=\"I appreciated Richard Smith\u2019s recent discussion of mental models\u2014too often, I think, we simply carry on with practice as usual (or, \u201clife as usual\u201d) without sufficient critical attention to the [...]More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/bmj\/2015\/06\/16\/william-cayley-to-doctor-is-to-diagnose\/\" \/>\n<meta property=\"og:site_name\" content=\"The BMJ\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/bmjdotcom\/\" \/>\n<meta property=\"article:published_time\" content=\"2015-06-16T14:52:00+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2015-09-22T13:23:40+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2-243x300.jpg\" \/>\n<meta name=\"author\" content=\"BMJ\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@bmj_latest\" \/>\n<meta name=\"twitter:site\" content=\"@bmj_latest\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"BMJ\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"4 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2015\\\/06\\\/16\\\/william-cayley-to-doctor-is-to-diagnose\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2015\\\/06\\\/16\\\/william-cayley-to-doctor-is-to-diagnose\\\/\"},\"author\":{\"name\":\"BMJ\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/#\\\/schema\\\/person\\\/ba3da426ed20e8f1d933ca367d8216fe\"},\"headline\":\"William Cayley: To doctor is to diagnose\",\"datePublished\":\"2015-06-16T14:52:00+00:00\",\"dateModified\":\"2015-09-22T13:23:40+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2015\\\/06\\\/16\\\/william-cayley-to-doctor-is-to-diagnose\\\/\"},\"wordCount\":729,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2015\\\/06\\\/16\\\/william-cayley-to-doctor-is-to-diagnose\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/files\\\/2014\\\/07\\\/bill_cayley_2-243x300.jpg\",\"articleSection\":[\"US healthcare\",\"William Cayley\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2015\\\/06\\\/16\\\/william-cayley-to-doctor-is-to-diagnose\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2015\\\/06\\\/16\\\/william-cayley-to-doctor-is-to-diagnose\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2015\\\/06\\\/16\\\/william-cayley-to-doctor-is-to-diagnose\\\/\",\"name\":\"William Cayley: To doctor is to diagnose - 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