Medical Decision Making
Updated: Jan 4
Perhaps no other symptom causes such anxiety as the feeling and perception of pain. It is the most frequent presenting problem I see in my practice and the number one reason most of my patients seek consultation and treatment. Chronic musculoskeletal pain is a challenging clinical problem often accompanied by negative emotions associated in dealing with the intrusive nature of the pain they experience on a daily basis. The understanding, evaluation and explanation of everything that’s going on to cause that pain requires identifying the exact cause(s) of the problem and often the presence of a combination of problems.
The unique and principle skill of a physician is in identifying the cause, set of causes, or source of a disease or condition. It is the nature of making of a diagnosis. Making a diagnosis is both an art and a science. No appropriate or effective treatment can be initiated without a diagnosis. The root of the problem, the reason behind the manifestation of an illness, the cause of the symptoms. It answers the question why. Why am I feeling like this, why do I hurt? Why am I in pain?
The able diagnostician requires experience and a thorough knowledge of systematic medicine and their practice specialty with attention to detail and intuition based on prior knowledge. They practice critical thinking and look beyond the obvious to help patients solve their problems. Their experience uncovers subtleties that can often be overlooked. They are relentless questioners, relentlessly seeking answers and more importantly know what questions to ask and what answers make sense. The best doctors combine good technique with good diagnostics. Recommended procedures are judiciously performed in partnership with a well-informed patient.
Skillful diagnosticians do not oversimplify or overcomplicate a presenting problem. To do so would result in under treatment or over treatment. They understand test characteristics and the benefits and limitations of diagnostic testing to provide critical information for a correct diagnosis. Establishing a responsible diagnosis is not merely a classification scheme or a ruling out of possible causes. It requires insight, experience, detailed information gathering, hypothesis and probabilities based on the individual patient. It is an ongoing assessment and a feedback loop that may require a long-term relationship and not a minute clinic to resolve. This is not the model of corporate medicine nor the expectation of patients seeking immediate answers to often complex medical problems. In some cases immediate certainty is unattainable. The diagnostic process is often time dependent and for patients and their families can feel disjointed and confusing. The clinical confidence of a good diagnostician establishes and reviews probable causes along the way leading to a more definitive answer and the best course of treatment.
This not in the skill set of all health care providers and although medical diagnostics is part of every medical school’s curriculum patient assessment and diagnostic reasoning needs greater emphasis and may not be every student’s strong point. Like in all academic studies some students are prone to assume their diagnostic and therapeutic decisions are infallibly correct while some remain so tentative that appropriative treatment may be delayed or never received. Preparing students to become good diagnosticians means teaching them to never assume symptom-to-diagnosis is always a lineal path with a scientific approach to problem solving that is not in every student's tool box. A background in science once relative to medical education has been lost as prerequisites have been fast-tracked and certain programs allow students to enter medical school who have never taken a science class as an undergraduate. While this non-traditional approach offers diverse life experiences there is a certain mind set that is achieved through scientific course work and the action and rationale behind the science that is beneficial in the practice of medicine. Diagnostic and treatment options are expanding and changing at an accelerating rate. Evolving technologies provide tools to augment clinical decision-making. A number of these exist and are being used by medical schools and physicians around the country. But a technology based diagnostic process without the necessary critical thinking skills to support it may provide patterns but not lead to the whole.
As both a sign and symptom, the question why am I in pain deserves a responsible diagnosis. It begins with the classic patient history, interview, physical exam and diagnostic testing. However depending on the severity and status, the subtleties and cognitive implications often associated with certain diagnoses may require much more. Missed or misdiagnoses, therapies, procedures and medications that mask or extend symptoms rather than address the root cause drain and misdirect our health care resources. We need more skillful diagnosticians who are soundly based in the sciences, critical thinkers, active listeners and problem solvers with training that makes them confident in their skills with judgement under uncertainty.
Medical-decision making is an effectual part of establishing a diagnosis. The complexity of the diagnostic process cannot be watered-down. Good diagnosticians effect good medicine. The root cause of why our health-care system is perceived to be failing is multi-faceted. Whether it be politics or funding, social injustice or misdirected influence, the importance of training responsible diagnosticians and supporting skilled diagnostic sages should not be overlooked or else we will all be feeling the pain of an ineffectual health care system promising much but delivering little.