Articles

Clinical Decision Making: Part I

I practice in a university clinic which functions partly as a tertiary referral center, which means we get referrals from other specialists. I also get many referrals for second opinions. Sometimes the entire cause for the patient’s desire for a second opinion, it seems to me, is the simple fact that they did not understand the reasoning of the previous specialist. They were given a diagnosis and a course of treatment, but not an explanation of how their doctor arrived at those conclusions.

I am not being judgmental – different practices are under different pressures and time constraints, and it can be very difficult to gauge a patient’s understanding. Often the physician and the patient are proceeding based upon differing assumptions and narratives that are not expressly stated. The doctor may think they have explained the situation entirely, but simply did not confront misleading assumptions they were not aware their patient had.

This is part of the advantage of engaging the public about health issues and confronting pseudoscience, myths, and misconceptions – you develop a deep awareness of how the general public thinks about medicine.

Carl Sagan warned against scientists becoming a “priesthood” with inaccessible knowledge and jargon, and this pertains to the applied science of medicine as well (perhaps especially). We need to engage with the public so that there is a general understanding of not only the findings of science but how science works. In the context of medicine, this means understanding clinical decision making – how doctors think.

Toward that end I plan on writing a short series of posts that explore various angles of clinical thought. These are talks I have had with medical students, residents, and my patients, to make my thought process as transparent as possible. I have found it to be extremely useful and a worthwhile investment in time.

The Dr. House syndrome

Patients often come to their doctor’s visits with a hidden narrative, a narrative I call the Dr. House approach. This is a narrative the public has largely learned from watching doctors on TV. It is also a perfectly reasonable narrative, and is not wrong as far as it goes. It’s just very narrow and incomplete.

The narrative is this – a patient has an illness (a certain set of symptoms), and that illness is caused by a specific pathological process or disease. The job of the physician is to be smart enough to make the correct specific diagnosis, which will then lead directly to a cure and resolution of the illness.

When this sequence of events does not occur or fails for some reason it is solely due to the fact that the physician simply did not make the proper diagnosis, so they should try again, order more tests, or refer the patient to someone with greater knowledge or more appropriate expertise.

On TV at least, Dr. House always eventually makes the correct diagnosis and saves the day.

Sometimes this is actually how medicine works. In fact doctors love telling each other stories about the complex or difficult case that they eventually diagnosed, especially when that further led to a cure, or at least an effective treatment. Often these stories are formally told as case reports or presented at conferences. These are fascinating stories because they are the exception, rather than the rule, of our day-to-day practice.

Other clinical pathways

While this is one possible pathway that diagnosis and treatment may take, it is not the only legitimate pathway. Here there is much variability by specialty. For most specialties, however, most patients will present with common ailments and diseases (common things are common – it may seem obvious but we do have to constantly remind ourselves of this – in fact this one point is worthy of its own post).

Diagnosing common conditions often is a matter of making a specific diagnosis and treating it. Patients have hypertension, diabetes, multiple sclerosis, etc.

What I am discussing here are those patients with something other than discrete, common, and easy to establish diagnoses. How do we approach such cases?

Ruling out

It is often as important to know what a patient does not have as knowing what they do have. We order some tests to rule out diagnoses that are possible, serious, and/or treatable. (An algorithm as to which diseases to consider and which tests to order can be the topic of a future installment in this series.)

It was surprising to me when I first realized how upset some patients can get when you inform them that they do not have a horrible diagnosis. I actually had one patient cry when I gave them the “good news” that their test was negative. That’s because I had yet to understand the narrative under which they were working. They were thinking diagnosis leads to treatment leads to cure – no diagnosis, not treatment.

I have since learned that I have to explain to patients as I am giving them their results that it is a good thing when certain tests come back negative. They do not want to have the diagnoses I am ruling out.

Further I explain that it is sometimes better to have no diagnosis than to have a bad diagnosis. Patients in whom all the tests come back negative (depending on the clinical situation) often do better than those with a specific diagnosis.

Further still, it is often not necessary to have a specific diagnosis in order to treat an illness.  (Again, this is very specialty-specific – surgeons do need a specific diagnosis most of the time, whereas neurologists often have to proceed without one.)

To treat without a diagnosis

To summarize everything above, an alternate narrative to “diagnose, treat, cure” is this: Rule out everything bad, understand the phenomenology as best as you can, then treat symptomatically. This may seem less satisfying, but it is often the preferable situation (again – you do not want to have a horrible diagnosis just to have a diagnosis).

Migraine is an excellent example of this. Patients present with a set of symptoms that we recognize and categorize as a migraine. There is a great deal of variability, however, and many patients may present with an atypical migraine, or migraine-like syndrome. There is no way to objectively make this diagnosis, no positive diagnostic tests.

The diagnosis is partly based on understanding the phenomenology – what kind of process is happening. It is also partly based upon ruling out other things that can cause similar symptoms (like a brain tumor). We then treat based upon a categorical diagnosis – the kind of process that is likely happening. Response to treatment then becomes the best confirmation we can get that the diagnosis is probably correct.

This may all sound very unsatisfying, but this just exposes yet another difference between public and expert narratives. Doctors learn to think in terms of what is likely to happen. How is this patient’s story going to play out? After years of practice you develop a perspective on this, and you realize that it is not a terrible thing when all the tests come back negative. Those patients may do quite well.

Another way to think about the above approach is this: The diagnostic workup is focused on finding active processes and pathology, especially those that are treatable. We then treat what we find, in addition to treating symptoms to improve quality of life. At no point in this process do we need to establish a specific diagnosis.

For example, I see patients with nerve damage (neuropathy). First I establish that the patient’s symptoms are due to nerve damage and characterize that as best possible. Then I look for any active process or anything treatable that might contribute to poor nerve health. I may find that the patient has a low vitamin B12 level. For many patients I still have no idea if the low B12 is causing or contributing to their neuropathy. Except in advanced cases, this is difficult to determine, and I won’t get a nerve biopsy just to confirm this. Instead I will just replace the B12.

Categorical and vague diagnosis

Another important distinction to make is that not all diagnoses are created equal. This too will be the topic of a future post, but for now suffice to say that there are hierarchies of diagnosis, and different types of diagnosis. Not all diagnostic labels refer to a specific and distinctive pathological entity. Sometimes we can determine what type of process is happening (an inflammatory process, for example) but not get more specific than that.

In other words, making a diagnosis is not a black or white, all or nothing proposition.

This approach to some patients has led, in my opinion, to the creation of vague diagnostic categories. This is because we need something to label patients in whom we have ruled out everything specific. These categorical diagnoses can be useful, but also a trap if you treat them as if they were a specific pathological diagnosis.

Fibromyalgia is the poster child of this phenomenon, in my opinion. It is a convenient label for anyone with muscle and connective tissue pain (myofacial pain) that is otherwise undiagnosed. Sometimes clinicians will call such a label a “garbage pail diagnosis” – we throw everything in that we cannot label more specifically.

This can be a useful placeholder, it can be useful to put the diagnosis into its proper category in terms of which kind of process is happening, and it is convenient short hand. In this case fibromyalgia may also be a specific disease, with specific findings, but it is used as a catch-all for any myofacial pain syndrome.

I prefer to use the term “myofacial pain syndrome” because it does not imply more specificity than actually exists. There is a bias, however, toward labels that sound like specific diseases.

Don’t be complacent

All of this is not to suggest that we should be complacent with less than complete knowledge. This is a tricky balance that also benefits from experience. We have to understand the limits of our knowledge and technology, and understand how to approach and treat patients in whom we will not make a specific diagnosis. But this should not lead to complacency – accepting too quickly that we don’t have a diagnosis.

The most important factors in determining how aggressive our posture should be toward making a more specific diagnosis is whether or not we have found specific pathology, and how the patient is doing clinically. If the patient is stable or improving, and/or responding to treatment, it may not be necessary or advantageous to continue ordering more diagnostic tests. If the patient is progressively getting worse, however, this suggests the need for more information.

Also, sometimes tests come back negative and sometimes they come back with abnormal but non-specific findings. For example, an MRI scan of the brain may find a “lesion” (a deliberately vague word) but not show specific features that would allow for a diagnosis of what the lesion is, exactly. We now have possible evidence of a pathological process, and this warrants a more aggressive workup than if the MRI scan came back pristinely normal.

Conclusion

The goal of this series of posts is to help physicians and patients communicate more effectively by exploring and understand the various assumptions and narratives that each bring to the clinic visit. This is an exercise in metacognition – thinking about thinking, in this case thinking about how doctors think.

As you can see, it quickly gets complicated. I have raised many points here, each of which deserve further exploration. The comments are likely to raise points and questions that I can also explore further in future posts.

In approaching this series the most challenging aspect was figuring out how to divide up the various topics. They all are interrelated in a web of decision-making. Hopefully the result was not too disjointed, but I will attempt to keep referring back in future posts and hopefully it will all come together in the end.

Other entries in this series

Part II
Part III

Posted in: Science and Medicine

Leave a Comment (32) ↓

32 thoughts on “Clinical Decision Making: Part I

  1. Janet says:

    I have never sought a second opinion. I have changed doctors once or twice because I did not like the way I interacted with them, and I have stayed with at least one specialist whose manner and personality I despised because I thought (I looked into it) he was an excellent surgeon and trusted him to fix my shoulder. I told him point blank what I thought of him and he improved in subsequent appointments.

    My personal experience is of little relevance, and I only relate it because I’m not sure what I’m supposed to take away from this post. I will have more coffee, shovel more snow, and then reread–or get a second opinion. :-)

  2. windriven says:

    Second opinions are useful when one does not trust the soundness of the first opinion. One of my employees was seeing an orthopod for pain in her thumb. The orthopod wanted to perform what amounted to exploratory surgery as radiology disclosed nothing of note. I suggested that she get a second opinion and helped her to find an orthopod who did his residency in a good program and who specialized in hands. She switched to the new physician and was able to resolve the problem in short order with stabilization and PT.

    My reason for suggesting a second opinion is that the first physician was unable to make a diagnosis and, rather than choosing a course of trying various therapies to achieve mobility and palliation, chose instead a very invasive approach to what was basically a very minor condition.

    But I’m basically in agreement with Janet. I rarely seek second opinions in my own care because I spend a good deal of effort choosing my physicians in the first place.

    * * *

    “I prefer to use the term “myofacial pain syndrome””

    Why is the adjective idiopathic falling out of use? It seems that idiopathic myofacial pain describes the condition as precisely as it can currently be defined: pain arising at the interface between nerves and the surrounding fibrous tissue but of poorly understood etiology.

  3. Idiopathic is still used commonly among physicians. I try not to use it with patients because it is jargon. Yes, I know, so is myofacial, but the fewer terms I have to explain the better.

    Second opinions are also useful when a judgment call is required, and you want to take the consensus of more than one person’s judgement. It is not necessarily a vote of no confidence in the first physician, although of course it may be.

    Another use of the second opinion is to a more specialized or more appropriate specialist. This is technically a tertiary referral.

  4. Jeremy Praay says:

    Thank you Dr. Novella.

    I had just recently had this conversation with a friend of mine, regarding how diagnoses were made, and the (often) relative uncertainty involved in these diagnoses. I think you must have read my mind…

    We often hear the phrase “consistent with” to describe a diagnosis, but that does not necessarily mean that the patient has that condition. e.g. The symptoms of Celiac Disease, upon presentation, are consistent with IBS, and quite often that is the first diagnosis that is made. If treatment is unsuccessful, further tests may be done, and hopefully the proper diagnosis will come later. But when no further testing is done, and someone simply assumes they have really bad IBS, then it’s a serious problem. The patient has a responsibility as well. Most physicians are not going to lay in bed at night wondering if the patient had some rare disease (unlike Dr. House). But do they always properly express their uncertainty to the patient? And how much uncertainty should be expressed? It’s a tricky situation. To the layperson, an honest physician may appear to be a fool. Whereas the overly confident physician, can cause indirect harm.

  5. WilliamLawrenceUtridge says:

    Jerome Groopman’s How Doctor’s Think, which I swore was reviewed here by Dr. Hall, but can’t find the post, was an OK read about this. Long-ish and tedious-ish, and I really didn’t like the far-too-long part where he talked about God and faith. For some people this discussion is not just unhelpful, it’s a downright turn-off that would make me want to seek another doctor; I’m OK with you saying “there’s nothing more we can do” rather than “It’s in God’s hands”, thanks. But still, it was interesting enough to retain my attention and did have some good points. I did like the opening vignette, where the doctor basically said “we’re ignoring your previous file, tell me what’s happening in your health, starting from the beginning of the problem”.

    Really looking forward to the rest of the series, one of my favourite parts of this blog is getting small windows into the brains and daily practices of doctors!

  6. mousethatroared says:

    A very interesting article. In general, I wish that doctor’s would be more clear about the diagnostic processes, at least when dealing with more complicated diagnostic issues.

    For instance, I have had quite a few health professionals tell me, “You don’t have X, and that’s a good thing*!” They completely seem to miss if they don’t follow through with some sort of plan for handling my symptoms – at least a recommendation on another specialist to see – then they are leaving me hanging in the wind and that is NOT a good thing.

    Also, a some big picture would help. The chirpy reassurances that “you don’t have seasonal allergies and that’s a good thing, you should be happy!” or “Well, the good thing is your TSH levels are normal” fall a bit flat when the next possibility on your referral list from your internist is the rheumatologist due to high titer of anti-nuclear antibodies, skin symptoms and intense fatigue. Which would you rather have as the cause of your fatigue, hypothyroidism or systemic autoimmune disease? BUT I’m guessing most neurological conditions fall toward the heavier end of the ‘rather not have’ have scale, so I’m guessing SN doesn’t make that mistake too often.

    I’d also prefer if medical folks did not do the “Your test is negative for X – You don’t want to have X – that’s a horrible disease” if I’m a candidate for X and X can develop over many years. Really, that’s just not that comforting.

    But another thing…
    Vague diagnostic categories based on suggestive findings for treatment are great, if all doctors use the same system, but IME they don’t*. Some doctors will treat patients with tests suggestive but not conclusive of systemic auto-immune disease with the safer medications as a trial, but other doctors look at the same results and consider the diseases “ruled out” because the patient doesn’t meet specific disease criteria. I’ve read a number of patients in forums who get pulled off of medications that are helping them because they had to change doctors due to a move, insurance, etc and the new doctor doesn’t recognize the vague diagnostic category of undifferentiated connective tissue disease or mixed connective tissue disease or someone who is basically one witnessed rash or mouth sore away from a diagnoses of Lupus (or is the wrong sex for their ankylosing spondylitis).

    Okay, glad I got that off my chest – and my apologies to Steven Novella, because it was more the topic that brought on the rant. I think it’s an excellent informative article.

    I would add, I think the relationship between patient and doctor will often function more effectively when both folks remember and communicate that the point of the meeting is to help the patient with their symptoms or their health not merely to find a diagnoses.

    *I recently read an article that claimed only about 50% of doctors follow the Standard of Care of their speciality, so I guess inconsistency isn’t surprising.

  7. FulfilledDeer says:

    So…..not to be that guy, especially since I’m not even sure I’m right….but isn’t it myofascial?

    Also, I really look forward to more of these.

  8. mousethatroared says:

    @Steven Novella – As an aside, My GoogleU degree in aches and pains has lead me to believe that myofacial pain syndrome and fibromyalgia are two distinctly different diagnoses. In myofacial pain syndrome, you have trigger points of localized pain that may send referred pain, that are muscle or connective tissue based. In fibromyalgia you have wide spread pain with tender points that respond to light pressure (different areas than MPS). It sounds like a widely held theory of fibromyalgia is heightened CNS sensitivity. While for myofacial pain syndrome the theory seems to be knots or tensed muscles that compress nerves. These are my laymen’s summaries, maybe not entirely accurate. :)

    In this article is sounds like you are saying that the two conditions are interchangeable. That makes me curious. Am I misunderstanding something?

    Perhaps not anything that needs to be addressed now…maybe food for a future article by someone.

  9. Harriet Hall says:

    @WLU,

    I did indeed review Groopman’s book, but not here. My review was published in Skeptic magazine and is available online at http://www.skeptic.com/eskeptic/07-10-24/#feature

  10. nwskepboy says:

    About migraines. They suck badly.

    I’ve had migraines since childhood. They paralyze me. Or give me ataxia. Either way, they make me weak as a kitten. My doctor knows the whole story. He’s ruled out cluster headaches and serious neurological problems, we’ve identified triggers (artificial grape it the worst one), and I don’t get auras so they come with no warning.

    We’ve tested out treatments, none seem to work. Immitrex is useless, other prescriptions don’t have any positive effect, OTC migraine pills don’t help, and sedatives/opioids are out of the question, I won’t take opiods unless I absolutely must, and then only in the smallest dose possible.

    I suffer from these about once a month, and they have been getting worse in recent years.

    I guess I’m a wacky atypical case, and I’m glad the migraines don’t mean I have a tumor or anything. It’s just so dissatisfying to have real pain, real bad pain, that I can’t really do anything about. It gets in the way of schooling and social life in that if I feel one coming on, I have to go home and lie down with a bucket.

  11. Aidan says:

    “We then treat what we find, in addition to treating symptoms to improve quality of life. At no point in this process do we need to establish a specific diagnosis.”

    I fear the SCAM crowd might quote mine this and turn it into their often repeated straw man argument that real medicine only treats the symptoms while SCAM can somehow magically treats unknown underlying causes.

  12. Alia says:

    I’m afraid I’m one of those patients frustrated with lack of diagnosis. Badly frustrated.
    The thing is, for a year or so I’ve been suffering from runny nose. Not all of the time, but often, gets worse in certain situations. Having strong family history of allergies and a few allergies of my own, I went to see a specialist. He first put me on medicines used to treat allergy. They helped. Then he ordered typical skin tests – no reaction. Then he ordered several other tests (nasal cytology, among others), no clear results. So I heard that he does not really know, I should use nasal sterides and come back next month, maybe he will have another idea. I stopped seeing him, I went to his private practice and had to pay a lot for each visit and each test he ordered. At the moment I’m trying to get used to my runny nose (always keep a packet of tissues handy), most of the time it’s not that bad. But at the same time I’m frustrated, I’ve spend half a year and a lot of money, and the result is only a diagnosis of exclusion.

  13. mousethatroared says:

    Alia – Yeah – me too. You can check out or ask your doctor about, Vasomotor Rhinitis or non-allergic rhinitis. As far as my doctor has told me, treatments are similar to allergic rhinitis, but allergy shots won’t help. Some other allergy type medications can, though…although I don’t remember the specific ones.

  14. yodeladyhoo says:

    This is a helpful topic. Thank you!

    Of course we’ll all personalize it with our personal experiences. In your essay you talk about ruling out the worst possibility. Many women with ovarian cancer regret the time spent ruling out lesser possibilities. Some are treated for irritable bowel, irritable bladder, GERD, etc. for some months before ovarian cancer is considered. My general understanding is the guidelines say to assume the most common condition first, which makes perfect sense to me. It’s hard for patients to know when to conclude that if the treatment doesn’t work, the diagnosis is probably wrong. And it seems that patients referred to a specialist such as a GI specialist or urologist sort of get dead-ended if their treatments don’t work. It takes quite a bit of assertiveness to go back to the PCP and ask for a new approach, especially because when a treatment doesn’t work the first thing the patient does is abandon the treatment, and the doctors can’t be sure the patient ever gave it a fair trial. Communication is everything!

    @Alia I can’t resist giving unsolicited advice from a totally unqualified amateur. You might try getting a dental checkup. An abscess or periodontal disease in the upper jaw can make the nose run like a sieve (sure did in my case!) Wouldn’t hurt, might help.

  15. windriven says:

    @FulfilledDeer

    “…myofascial?”

    Doh!

  16. WilliamLawrenceUtridge says:

    I did indeed review Groopman’s book, but not here. My review was published in Skeptic magazine and is available online at http://www.skeptic.com/eskeptic/07-10-24/#feature

    Perhaps that’s where I saw it, but I vividly remember a discussion of Dr. Groopman’s hand surgery in the review, and the decision making process he went through to decide on a doctor and course of treatment. That seems to be missing from your review (though you mention his back problems in discussing his Anatomy of Hope). Perhaps it’s source confusion.

    Re-reading my review on google books, I apparently hated it a lot more back then than I do now. I still prefer Dr. Novella’s abstract approach over Dr. Groopman’s anecdote-heavy book.

  17. Badly Shaved Monkey says:

    I’m a vet, so there are some differences in my world, not least the fact that clients are often paying literally from their own pocket for any testing I do. Bear in mind I am in first opinion general practice, which is quite a long way from being a neurologist in tertiary-level human medical practice. This means that common things really are common in my caseload, which has important effects on the arithmetic of positive and negative predictive value of testing.

    I definitely use a couple of strategies that align with what Dr Novella is saying.

    1. In a lot of instances I pause to explain that whatever their animal is likely to have, we have limited treatment options and these often have overlapping actions (e.g. hypoallergenic diets are typically also highly digestible). A trial treatment regime can be applied without knowing the underlying specifics of the pathology of the case. I try to tell clients I am looking for certain red flags in the presentation that dictate we should do some rule out testing at an early stage before we risk going a long way down the road having ignored an important and specific diagnosis that has a specific treatment. Dogs get a lot of chronic diarrhoea. A few cases will have exocrine pancreatic insufficiency. Most cases end up with successful symptomatic management, which is good because an exhaustive work-up leads to surgical bowel biopsies and these are notoriously controversial in their interpretation, but if you bring me a really skinny dog with watery diarrhoea we ought to tat for EPI sooner rather than later because it has specific treatment and they can struggle to recover lost body condition so you don’t want to have lost too much before you make the diagnosis.

    2. In trying to allocate money for investigation, I talk about trying to ‘diagnose the treatable’, which is another version of what I have just said. We want to check for the diagnoses that have specific treatments before we get too committed to a path of symptomatic management and trial therapy.

    3. I try to explain the issues around NPV and PPV, but in non technical terms, by explaining that every test give false positive results and if we screen for every obscure diagnosis all the time our “positive” results end up being dominated by false positives, which can lead to inappropriate treatment, which has side effects unbalanced by benefit. False positive tests can also lead to further diagnostic testing that becomes more invasive and therefore poses risks of harm.

  18. Badly Shaved Monkey says:

    One other thing, my years of interaction with the SCAM world has taught me the power of a good narrative, for that is all they have and yet they run profitable and busy practices. I try to maintain a meta-awareness of my discussion with the client to make sure they get that good narrative from me so that the, hopefully, well-founded treatments I give are given the supportive context of that narrative.

  19. Badly Shaved Monkey says:

    Various typos, but I’ll correct this one;

    “we ought to test for EPI”

  20. BillyJoe says:

    Alia and Michelle,

    Michelle, I think you hit the diagnosis on the head. I think Alia’s symptoms are those of vasomotor rhinitis. But I think you are wrong about the treatment. The treatments for allergic rhinitis do not work for vasomotor rhinitis. The only thing that seems to help for vasomotor rhinitis is saline flushes. But perhaps I’m basing this too much on personal anecdote.

    And, Michelle, your description of the symptoms of myofascial (yes, it is myofascial) are those that I recognise as symptoms of fibromyalgia, so perhaps Steven Novella is correct that they are interchangeable. Or perhaps I think agreeing with Steven Novella is a pretty safe bet.

  21. mousethatroared says:

    @BillyJoe – The reason I say I think some allergy medicines work is based on my allergist recommendation. He said (I’m paraphrasing something I heard and he spoke very fast) even with non-allergic rhinitis the symptoms are still (in part I think) cause by mast cells…something – So some some of the medications that work on allergic rhinitis also work for the vasomotor type. Clearly I’m not a medical person. I was only hoping to provide a lead. (Hope it wasn’t annoying)

    Personally I use Fluticasone propionate (cortisone nasal spray), but I use it for the associated sinus congestion, which I find worse and more chronic than the runny nose. I don’t really recall how well it works for the runny nose. My runny nose is intermittent. When I eat a warm food, when I go outside in the cold, dust, smoke, etc. I just try to carry a lot of tissues. I have also heard from doctors saline washes can be good as well.

    Regarding the myofaS*cial pain syndrome and fibromyalgia. I wasn’t really saying the Steven Novella was wrong. I was saying I saw a discrepancy and I wondered. Maybe there are two valid ways of approaching the issue depending upon whether you are looking at the problem from a physical therapy perspective or a neurological perspective, maybe I’m happening upon theoretical information that isn’t well established in the medical field or my separation is complete quackery. I don’t know. That’s why I asked.

    Here’s a couple of links to abstracts – for a more specific description. http://www.ncbi.nlm.nih.gov/pubmed/7595112
    http://www.ncbi.nlm.nih.gov/pubmed/19015861

    But I fully acknowlege this is a very tertiary subject. I don’t want to derail the thread. That’s why I put it out there for maybe a future article.

    *spelling facist – doh Godwin. :)

  22. DugganSC says:

    And, of course, we still have to deal with the interaction of doctors and insurance companies. Insurance companies want to keep costs down, so they insist on approval for every step. And, in their defense, some hospitals and doctors are known for ordering every test possible, whether for liability purposes (I don’t think any doctor has been sued yet for ordering tests for potential treatable conditions that fit the symptoms) and also because in-house testing can be immensely profitable. I know my wife has been dealing for facial (not fascial :) ) numbness for the past few weeks and she’s getting bounced from one diagnosis to another, each time the insurance company insisting on a period of consideration before approving the next test. So far, the only thing they’ve figured out is that her blood tests normal and she has a swollen lymph node (and pleural scarring in the lungs, but I get the impression they think that’s unrelated).

  23. mousethatroared says:

    DugganSC – what do you mean – insurance company period of consideration? Are you saying that they are delaying running tests until insurance company approval or just that the insurance company is delaying payment until they have adequate documentation of need from the doctor.

    IME (as a patient) requisitions for tests include the ICD code of the problem being looked into….such as thyroid nodule and the code (which I don’t know) and as long the test being ordered is on the insurance company data base matching the code, you are good.

    I’m not disputing your concern. I just don’t understand what is going on.

    Hope they figure it out for her soon.

  24. pharmavixen says:

    A review of the evidence for a physiological basis for fibromyalgia would be an interesting article for this site, though it would probably generate as many comments as the recent articles of which I don’t need to name.

  25. Alia says:

    @yodeladyhoo – thanks for your suggestion but I don’t think it has anything to do with my teeth. I have regular dental check-ups and following surgical removal of two wisdom teeth, everything else is in perfect condition.
    @mousethatroared, BillyJoe – nasal sterides seem to be working for me. The thing is, everything has its side effects and I’m not really sure what is better for me – taking nasal sterides and then possibly suffering from consequences, or just suffering runny nose and carrying tissues.
    And in a way (which overlaps with what dr Novella said) I would be happier if I was diagnosed with a straightforward allergy, let’s say to birch pollen or Cladosporium. Then I would know what to avoid (like dank and musty rooms) and I would have a chance to get allergy shots. Which of course are unpleasant, take a lot of time (you have to visit the doctor’s office at regular intervals) and are costly. But at least I would have a treatment and a possible cure, not just symptom relief.

  26. mousethatroared says:

    Alia – Yeah, I totally see where you are coming from. It’s a drag when the conditions that are possibly curable or have concrete low side-effect treatment options are excluded.

  27. DugganSC says:

    @MTR:

    They’re waiting on insurance company approval before doing the scan. As an update, the doctor just called her a bit ago and said that they had the MRI approved, but wanted to submit another test for approval, a cervical scan (which led to a funny conversation with my wife because she hadn’t realized “cervical” could refer to the neck, and didn’t understand what her cervix had to do with facial numbness).

    To be honest, my experience with doctors has also been that they do the test without checking for insurance, in at least two cases involving me getting stuck with all or part of the bill because the insurance company disagreed on the necessity of the test, although that might also have to do with the current Highmark / UPMC friction going on here in Pittsburgh.

  28. mousethatroared says:

    @ DugganSC – Not to make you feel worse, but that sounds pretty dysfunctional. Hope they work the bugs out of that system.

  29. BillyJoe says:

    Regarding insurance companies.

    Fortunately, in Australia, insurance companies do not hold any power over the practice of medicine – except for transport accidents and workplace accidents which are all privately insured. And it is in this area that we get a hint of how efficient such a system can be. Last year, a woman who had been involved in a car accident needed an orthotic for her foot injury. The insurance company needed a detailed letter of request from both her physiotherapist and doctor explaining exactly why she needed the orthotic and what other treatments had been tried to overcome the injury. They also referred her for a second opinion to an orthopedic specialist. Cost of orthotic: $500. Cost of approval procedure: more than $1000. Delay in treatment: 5 months.

  30. DugganSC says:

    @MTR:

    Yeah… unfortunately, UPMC is pretty close to the only game in town. They’ve swallowed up almost every medical practice in town. The ongoing feud is definitely dysfunctional, like something from a soap opera. UPMC is threatening to no longer take Highmark Blue Cross Blue Shield insurance. Their official reason is that Highmark had the temerity to invest in one of UPMC’s competitors in the area, threatening UPMC’s monopoly. Unofficially, their respective CEOs hate each other as a result of each having at one point worked for the other company and the minor incident where one CEO was caught sleeping with the other’s wife (I honestly don’t remember who slept with who and frankly don’t really care beyond where UPMC is threatening to no longer accept Highmark, which the majority of non-local companies here use). We’ll find out later this year how it will all fall out.

  31. mousethatroared says:

    @BillyJoe – yeah – you’re singing to the choir with me.

    @ DugganSC – shakes head – just when you think dealing with insurance couldn’t get any worse – throw in executive sordid affairs.

Comments are closed.