Diagnosis is only half the job

In clinic I have two jobs.

The first job is to diagnose. Chief complaint, history of present illness, past medical history, allergies, review of systems, medications (and vitamins and supplements and herbs and any pills or concentrated substances), social history including addictive substance use, family history, physical exam. What is my diagnosis? A clinical portrait of the patient.

The second job is to communicate and negotiate. I have to get a snapshot of the person’s medical belief system, their past experience with MDs, their trust or lack of trust, whether they are willing to take a prescription medicine. I have to try to understand their world view at this visit, at this moment in time. And it’s not static and may change before I see them again. If I can understand the person well enough to communicate with respect, with concern, with understanding, then we may be able to negotiate a treatment.

In clinic the other day I had a new patient who said, “I am not going to be pushed to take prescription medicine.” I responded, “That’s fine. I am not going to be pushed to do medical testing that I think is inappropriate, either.” She actually laughed and said, “Ok. That’s fair.” This is a patient who is coming from alternative treatment but wants medicare to cover her tests. After the visit she called and said that her provider wants a certain test before they feel comfortable proceeding with a therapy. I responded that I need a note and an explanation of the planned therapy before I will order the test. (Honestly, it’s an increasing trend that I get calls from patients with messages like “My orthopedist wants you to get my back MRI prior authorized.” and “My physical therapist wants my hand xrayed.” Our new office policy is: the provider has to communicate themselves, not via the patient. Also, it ain’t always so….)

I had patient once in the emergency room who said, “I have an antennae in my tooth. Get it out.” Her roommate nodded, looking terrified. This was after a fairly confusing complaint of tooth pain. I needed to think about an approach. I said, “I need to check on another patient. I will return.” I left the room in the emergency room and considered approaches. I went back in and said, “I am not a dentist. I can’t take out the tooth. BUT I can call a doctor to help with the sounds that you are hearing until we can deal with the tooth. The doctor is a psychiatrist.”

“Ok. Call them.” said the patient. The roommate practically collapsed with relief. Psychiatry said, yes, looks like psychosis and we have a safety contract and she will come in Monday. People HAVE actually had metal in their mouth that picked up radio sounds, but psychosis is much more common. Also, if you can say the station call sign that is a lot different than voices that are telling you to harm yourself.

I thought about my approach carefully. I did not want to argue about the tooth. I wanted her to agree to talk to psychiatry. So I told the truth: I can’t fix the tooth. It’s Saturday night. Here is what I can do. I never said, hey, I don’t think it’s the tooth, I think it may be a psychotic break. She may have known that it was not the tooth but been too terrified or too disorganized to tell me. And there was a small chance that in fact, it WAS the tooth.

It is not worth trying to “fix” or change someone’s world view. If they trust their naturopath more than me, that is ok. But it’s a negotiation: I am a MD and I will do treatments that I think are appropriate and safe and I may or may not agree with the naturopath or chiropractor or physical therapist or accupuncturist or shaman. But the goal in the end is NOT for me to be correct: it is to help the patient. Half the therapy is respect and trust and hope. And kindness.

The biggest problem with ten minute visits and the hamster wheel of present day medicine in the US is that the second job is often not possible. Complex diagnoses are missed or patients leave feeling unheard, not respected and frustrated. Time to make the connection and to understand is very important and is half the job. Physicians and patients are frustrated and it is only getting worse.


The photograph is my daughter and her wonderful violin/viola teacher, right before my daughter played for a music competition.


8 thoughts on “Diagnosis is only half the job

  1. In the UK we don’t have consistent doctors anymore and they can give at best 10 minutes of their time. I think you’ve brought up a very important point about the nature of medicine generally. The time that is needed to understand the patient. After all, if a placebo works, then it does suggest that healing is more than a physical phenomenon. I think the building of a mutual relationship helps trust and more appropriate expression of experiences and sensitive responses.

    • drkottaway says:

      There is ongoing research about placebos. Very complicated. Thank you.

      • Hope you write about it :) I’ve been interested in the use of placebo groups in faith healing experiments. If healing occurs in both groups then the conclusion is that faith healing doesn’t work – it’s a placebo effect. But isn’t that just as magical an explanation?

        • drkottaway says:

          My short answer is no. It is not the same. People in cholesterol studies have improved cholesterol with or without the “real” medicine. Part of it is the support and attention and they know they will be retested. So the “placebo” patients have improved numbers: so being in a study makes people do better.

          • I’m aware of research effects on participants and also placebo effects for a variety of medical conditions. But my point is that – how do scientists explain this effect? To just say that it is the placebo effect or that it is the support and attention they are getting is a description of variables that effect improvement, but not an explanation. However, if you say, as they know they are in a study that is testing cholesterol, all patients work to decrease their cholesterol through dietary changes – then that is an explanation. If you say it is because they believed the medicine worked so it worked, that is not a scientific explanation. I still argue that placebo effect as an explanation for what happened, isn’t actually scientific. What are the mechanisms that are going on at neural level that would make belief in a treatment work? Similarly for social support.

          • drkottaway says:

            Our understanding of the neural level has a very long way to go.

          • Agreed!!! Sometimes though, I like to have faith in the inexplicable. Why take the mystery out of such a wonder?

          • drkottaway says:

            All I have to do to find mystery is look at a leaf or a newborn: it’s all mysterious.

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