Hello my Zebras and Spoonies! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I am going to talk about the process that a provider goes through to give a patient a diagnosis. I’ve seen this topic come up fairly often in several of the groups I’m in and I think it would be helpful for patients to have a better understanding of the process and thinking that goes into the diagnostic process.
The first thing to know is that there are rules for making a diagnosis. The standards of practice dictates a certain set of signs and symptoms need to be present in order to diagnose a patient with something. This is important because it ensures that there are standards for each diagnosis and that every provider is using the same criteria when diagnosing people. It is also important because insurance companies require justification for payment. This means that the diagnosis and symptoms that you’re treating have to match and make sense if you want to be able to get paid for your services.
However, this adds a bit of a challenge, because people are complex and don’t always present the ways that the diagnostic criteria say they will. This is often because the research done on illnesses has historically been done on white males which largely limits our perspective of illnesses. It is also just because there are always a certain number of people that are outliers and won’t present in a classic way. Because of this, there is a method to go through to diagnosis a patient with something that is not presenting in the classic way. But it is more difficult and can lead to payment issues.
The next thing to know is that there is a method to the diagnostic process. The first step is data collection. This is getting your report of what is going on. Reviewing your medical history. Doing a physical exam. Then that data is compared to the diagnostic list in the provider’s head. From that, they generate what is considered the differential diagnosis. This is a list of all the things that the provider thinks could be going on. So, all the possible diagnoses.
There are some things to know about the data collection. The first thing to know is that there are two general categories of information that is collected: signs and symptoms. A symptom is a manifestation of disease apparent to the patient, while a sign is a manifestation of disease that the provider perceives. The sign is objective evidence of disease; a symptom, subjective. It is important to know that signs are considered more reliable than symptoms. This is because research has shown that people generally don’t make very good historians and don’t do well in keeping track of things. This is why I feel a medical journal is an immensely helpful tool that can give more credit to your personal report.
The other thing to know is that most of the time, the presenting signs and symptoms can be caused by many things. This is why a differential is created. Most providers also list those possible diagnoses in order of how likely they feel that is the diagnosis. Basically, they are going to start by looking for the horses before they start looking for the zebras even if your signs and symptoms fit the criteria for both. This is the biggest reason that getting a diagnosis can take a long time. The more possibilities there are to rule out, the longer the process will take.
Once they have the differential, they will decide which diagnosis to start with and they will order tests that will help them to determine if it is that diagnosis or not. Once the data from the testing comes back, they will reassess all the data and determine if they think that the diagnosis they were considering makes sense. If it does, you get the diagnosis. If it doesn’t, they move on to the next diagnosis and do more testing.
The thing about the majority of medical tests is that they are not going to give you definite answers. A positive result on a test usually indicates that the body is functioning a certain way and that can often narrow down the diagnosis, but it rarely only indicates a single diagnosis. It is also important to know that every type of medical test can have false positives and false negatives which can further confound the diagnostic process. Sometimes these inaccurate results are because the testing occurred too soon and the levels in the body haven’t reached a detectable threshold. Sometimes it is because the angle of the imaging wasn’t what was needed to see the abnormality. Sometimes it is a matter of interpreting the results. Sometimes the problem is that what ever you are trying to test for isn’t actively happening at the time the test is conducted. The point is, that these medical tests are complex and need context to be meaningful.
The other thing to keep in mind is that there is plenty of room for a provider to have a treatment style. There are generally two styles. The first style is to nail the diagnosis and the second style is to make the patient comfortable. Neither is wrong. Both have their pros and cons. But it can be helpful to know which style your provider is working from as this can help make sense of their approach to your care.
The first style is all about making sure that they get the correct diagnosis. The theory behind this is that the correct diagnosis will increase the probability that treatment will benefit the patient and not cause harm. With this approach, the provider will not start any kind of treatment until they are sure of the diagnosis. This is because they do not want to skew any results with any treatments they have started nor do they want to cause things to get worse by starting treatments without being sure of the diagnosis. The pro to this style is that the patient is likely to have a good outcome. The con is that the patient is likely to wait longer before they receive any kind of treatment.
The second style is all about addressing the symptoms that are bothering the patient. The theory behind this is that the diagnosis isn’t what’s most important, getting the patient to wellness is. With this approach, the provider will start treating the patient as if they have the most likely diagnosis in the hope of improving the patient’s condition while they begin the testing process. They will focus on making the patient more comfortable. The pro to this style is that the patient gets immediate treatment and often gets relief from troubling symptoms quickly. The con is that treatments can skew testing results or even make the condition worse if the presumed diagnosis is incorrect.
There is a third style which is a bit of the middle ground. This approach reserves the majority of treatments until the diagnosis is sure. What treatments are provided prior to securing a diagnosis are those that focus on stabilizing the patient, have a low risk profile and address high comfort needs (issues like shortness of breath and pain). This style has the pros and cons of both the first and second styles. The majority of providers work within this third treatment model.
The last thing to keep in mind with all of this is general patient prognosis. There are many times that a diagnosis is simply not pursued because knowing the diagnosis would have no impact on the patient’s care. Say that the patient is nearing the end of life and when doing a chest xray to evaluate the patient for aspiration the provider discovers that the patient has a lung mass. If the patient would not be a candidate for treatment or would not elect treatment for this mass then it doesn’t matter what the diagnosis for the mass is. This is a dramatic example, but it makes the idea clear. Just know that most cases of prognosis are more nuanced then that. Thus, a provider may begin by having a discussion of whether or not there is benefit to having a diagnostic work up.
In the end, I feel that it is important to know what you value as a patient. How important is it to you that you know the diagnosis? Should you know the diagnosis before you begin treatments? Don’t be afraid to discuss these issues with your provider. And keep in mind that what makes sense to you in one medical situation might not in another. Thus, as always, the most important factor for ensuring that you are getting the best possible care is to maintain open lines of communication with your provider. Be sure that you are asking them all your questions and don’t be afraid to tell them when you are not comfortable with the treatment plan that they are proposing.
In the world of the internet and getting information from google or other chronic illness warriors, we often go into our appointments with expectations and even self diagnosis. There are some things to keep in mind about this. First, the internet is a powerful and great resource. Don’t be afraid to look things up and do some research on your own. Just be sure that you are getting your information from sources that are creditable. If your provider doesn’t agree with your self diagnosis, be sure to ask them why they don’t think that diagnosis is correct. They should be able to explain to you why the data led them to the diagnosis. And you have a right to understand how they came to that conclusion. Don’t be too quick to shoot them down just because they came to a different conclusion then you did. You are the expert of your body and they are an expert in medicine. Both have an important and valuable perspective.
Well, that’s about it for my rambling today. Thanks for coming and spending some time with me. If you like what you read, click on that like button. It really does help! Until we talk again, you take care of yourselves!
Zebra Pig 