{"id":34654,"date":"2015-07-08T11:14:23","date_gmt":"2015-07-08T10:14:23","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=34654"},"modified":"2015-09-22T14:22:13","modified_gmt":"2015-09-22T13:22:13","slug":"william-cayley-diagnosis-what-its-not","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2015\/07\/08\/william-cayley-diagnosis-what-its-not\/","title":{"rendered":"William Cayley: Diagnosis\u2014what it\u2019s not . . ."},"content":{"rendered":"<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-31912\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2-243x300.jpg\" alt=\"bill_cayley_2\" width=\"178\" height=\"220\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2-243x300.jpg 243w, https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2.jpg 551w\" sizes=\"auto, (max-width: 178px) 100vw, 178px\" \/><\/a>\u201cPhew! At least you don\u2019t have something bad.\u201d<\/p>\n<p>\u201cI know doc, but what is it?\u201d<\/p>\n<p>I\u2019m afraid that in medicine, we too often focus on the former, and not enough on the latter.<\/p>\n<p>How often do we see patients admitted to hospital to \u201crule out\u201d an acute coronary syndrome? How often do we do a throat swab to \u201crule out\u201d strep throat? How often do we see imaging reports that come to the final conclusion that \u201csomething bad (embolism, pneumonia, etc) cannot be excluded.\u201d<!--more--><\/p>\n<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/2015\/06\/15\/richard-smith-diagnose-treat-and-cure-is-largely-dead\/\">Richard Smith recently made the argument<\/a> that doctors predominantly use \u201cfamiliar responses to familiar problems,&#8221; which I think is a great summary of <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/9988240\">using heuristics to make diagnoses<\/a>. However, one of the most common heuristics seen in medicine, is at least a simplification of the scientific approach of hypothesis testing\u2014pose a falsifiable diagnosis, then investigate.<\/p>\n<p>This works to a point\u2014but only to a point. Finding out what something is not, is only the first step toward finding out what it is. Patients with a sore throat don\u2019t just want to know they do NOT have streptococcal pharyngitis, they want to know what they do have and what to do about it. Similarly, when a patient has chest pain, to provide the reassurance that \u201cyou\u2019re not having a heart attack\u201d is only the first (even if very appropriate!) step. If the chest pain continues, the patient is going to want to know what it IS and what to do about it. Telling someone what is NOT wrong, only gets you part of the way in giving good care.<\/p>\n<p>Unfortunately, as valuable as the \u201c<a href=\"http:\/\/www.choosingwisely.org\/\">Choosing Wisely<\/a>\u201d and \u201c<a href=\"http:\/\/www.preventingoverdiagnosis.net\/\">Preventing Overdiagnosis<\/a>\u201d movements are, they also abet this tendency. \u201cPreventing Overdiagnosis\u201d is a good thing (after all, we are now finding and treating more and more pulmonary emboli, <a href=\"http:\/\/static.www.bmj.com\/content\/bmj\/347\/bmj.f3368\/F1.large.jpg\">but not actually reducing the PE related mortality<\/a>), but if the message is primarily about what NOT to do, that still leaves us without the resources or mental models for how to think about what TO do. Similarly, <a href=\"http:\/\/www.choosingwisely.org\/\">Choosing Wisely<\/a> has been a helpful campaign to point to where medicine has gone to excess, but 19 of the top 20 recommendations on the Choosing Wisely site start with either \u201cdon\u2019t\u201d or \u201cavoid.\u201d<\/p>\n<p>Going back to the chest pain illustration (and at the risk of shameless self-promotion, since this is one clinical area about which I occasionally write), in my last review article on evaluation of chest pain in the office, I tried to go beyond the focus on \u201cruling out\u201d to instead discuss other diagnoses beyond cardiac chest pain, <a href=\"http:\/\/www.jfponline.com\/articles\/editor-s-pick\/article\/chest-pain-tools-to-improve-your-in-office-evaluation\/a48c14ba150da0e57563a48747c26535.html\">and what one CAN do for them<\/a>. Similarly, while we easily fall into the habit of telling our patients \u201cit\u2019s just a cold\u201d (implicitly, it\u2019s NOT something \u201cbad\u201d), and often then recommending the unproven treatments of \u201crest and plenty of fluids,\u201d there have been some helpful evidence-based handouts published that give recommendations for what you <a href=\"http:\/\/www.aafp.org\/afp\/2012\/0715\/p153-s2.html\">CAN do to help a child<\/a>\u00a0or <a href=\"http:\/\/www.aafp.org\/afp\/2012\/0715\/p153-s1.html\">adult<\/a>\u00a0with a cold feel better.<\/p>\n<p>Diagnosis\u2014what it is NOT is simply \u201cexcluding\u201d the bad stuff. Diagnosis needs to be about careful attention to patient history, symptoms, and worries, then doing the best we can to identify what we think IS going on\u2014so we can give positive recommendations for what to do about it.<\/p>\n<p><em><strong>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<p>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":"<p>\u201cPhew! At least you don\u2019t have something bad.\u201d \u201cI know doc, but what is it?\u201d I\u2019m afraid that in medicine, we too often focus on the former, and not enough [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2015\/07\/08\/william-cayley-diagnosis-what-its-not\/\">More&#8230;<\/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-34654","post","type-post","status-publish","format-standard","hentry","category-us-health-care","category-william-cayley"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>William Cayley: Diagnosis\u2014what it\u2019s not . . . - 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\/07\/08\/william-cayley-diagnosis-what-its-not\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"William Cayley: Diagnosis\u2014what it\u2019s not . . . - The BMJ\" \/>\n<meta property=\"og:description\" content=\"\u201cPhew! 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