Fundamentals of Medicine: Diagnosis and Guidance (Not Just Treatment)

Non-clinicians skip over some of the most necessary underpinnings of Doctoring and speak too much about housekeeping issues: Blood Pressure targets, aspirin use, mass screenings, immunization rates and so on.

People without medical degrees could do those things. But there are steps that must be taken before we worry about the measurables. These are the essence of being a physician, what people ask for when they come to see us. Most people don’t come in and say “I need you to regulate my blood pressure” or “Help me lower my cholesterol”. They come in saying “I don’t feel good” or “Help me stay healthy”.

DIAGNOSIS

More than anything, people come to us to find out what’s wrong with them. They come with rashes, aches, fevers, coughs, “bunches” (the Maine word for lumps and bumps on their bodies) and concerns like fatigue, which could be a symptom of almost anything.

In that scenario, not to be melodramatic, making a correct diagnosis could be a matter of life or death, or at least wasteful spending of thousands of dollars and valuable time.

We don’t get enough credit by outside observers, like health care administrators, insurers and “consumers” for the value of our diagnostic acumen. It is the first fundamental of health care. Different diseases have different treatments and the success of medical care hinges on treating the right diagnosis.

A trivial example is a patient I heard of just recently with sudden agitation and high blood pressure presenting to the emergency room. Many hours and many tests after arrival – blood tests, EKG, CT scans and so on, he turned out to have urinary obstruction. A Foley catheter relieved the obstruction and cured his high blood pressure as well as his agitation.

A young woman came to see me a few days before graduation for a mild rash on her legs. Not only was she about to graduate; she was also planning a long trip afterward. The bloodwork I ordered STAT on our first encounter showed that she had acute leukemia. She was allowed a temporary leave from the cancer clinic to attend the ceremonies and then went back to continue her treatment. Today, she is the proud mother of a soon-to-graduate teenager. What if I, as she later said, had glanced casually at her skin and sent her off on a faraway trip with a prescription for a cream?

GUIDANCE

“Treatment”, the second part of the traditional duad, is too simplistic a notion, only useful for lancing boils and prescribing penicillin for strep throat. Most diseases are multifaceted and most patients have several health and disease considerations. Most diseases are also chronic, even ones we thought of as rapidly terminal earlier in our own lifetime, like HIV and an increasing number of cancers.

The physician’s role is not a knee jerk intervention, it is informing and educating the patient and helping each patient choose a plan of action that is right for them.

Primary Care does what Google can’t, it applies knowledge of the patient and of the relative importance of medical facts and factoids and offers guidance in the sense of ranking options.

Even when the treatment requires specialized care we have a role as guides. We help patients choose specialists depending on each patient’s particular medical problems and personal preferences – referral to a particular subspecialty and to a take-charge doctor or a collaborative one, for example.

As guides, we follow patients along on their journey, sometimes actively by showing what to do, sometimes only watching from a distance, ready to intervene if they stumble. We don’t just prescribe, we anticipate – we warn patients and their families of things that may come up at the next turn. It takes experience and expertise do that well, not just handing out mass produced information to meet “meaningful use” mandates.

Sometimes our Guide role requires us to talk about a different journey – not one back to health and function, but one of decline and death. We must be comfortable with that role as well as the cheerleader’s.

The almost pastoral duty we have is to instill and preserve hope. Although this is often for a cure involving certain obstacles or challenges, sometimes the hope we can offer is only the hope of feeling better and sometimes it is just of relief from suffering.

We live in an era of tweets, sound bites and intellectual shortcuts. Medicine doesn’t fit into that kind of mindset very often. Contrary to what some outsiders think, ours is a deeply cognitive profession of careful consideration and deeply personal counsel.

“Treatment” is simply a misnomer for what we do. Even when there is no cure, there is care.