Mar 20 2013
Clinical Decision-Making Part III
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All true enough, but of course you’re focusing on difficult, puzzling or problematic situations. Our popular picture of medicine is that it’s all about making difficult diagnoses, thanks to TV; and of course NEJM features one every week, as if this is the most important challenge that physicians routinely face. Most clinical interactions are about dealing with well-established conditions, or fairly straightforward presentations. The challenge, usually, is not so much to figure out the mystery of what’s biomedically wrong with the person, as it is to figure out the best course of action given the inevitable risk, cost and benefit tradeoffs and the difficulty many people have in following medical advice.
cervantes – I disagree. The factors that I discuss above are relevant to just about every history I take from a patient. It really is only a matter of degree.
Every patient history I take is distorted to some degree, and is also biased by the questions I choose to ask and how I ask them. Also, even when treating straightforward issues we have the problem of knowing what tests to order, what the results mean, and whether or not our treatments work.
I admit my own experience is biased since I am a specialist working in a university clinic. But I would not characterize these factors as only relevant to diagnostic dilemmas or particularly difficult cases. They are relevant to every case.
Also – I think good and experienced clinicians know a lot of this, even if they are not aware of the more general skeptical principle, what it’s called, and how it applies outside of medicine. They just learned the “clinical pearl” and apply it to their practice. So, many of these factors are being accounted for even in a routine evaluation. But even excellent clinicians will commit subtle forms of the above cognitive errors, although they can be minimized by being explicitly aware of them and vigilant in monitoring for them.
What I’m saying is that most of the time, your problem is not to diagnose the cause of the complaint — it’s pretty clear, for example, that the person has osteoarthritis, or an uncomplicated RTI, or is obese, or your labs show elevated h1Ac or whatever. What you need to diagnose is more about what the person wants, needs, understands, can do — it’s not about the Dr. House kinds of narratives. I’m talking about primary care, neurology is probably another matter.
I always dread the question: “So, how long has your shoulder (or whatever) been hurting?”
I confess I usually pull something out of thin air, and then immediately start revising it. Does this information actually help diagnose whether I have arthritis, tendonitis, or rotator cuff? Maybe she is just making conversation?
I suppose the length of time question has more meaning if the complaint is headaches or stomach or abdominal pain.
Thanks for furthering my logical thinking education, but since coming to this blog I have found that I follow almost everything I say to my doctors with, “but I could be wrong…it might just be an anecdote/placebo/a bad study, etc.
Janet ” I have found that I follow almost everything I say to my doctors with, “but I could be wrong…it might just be an anecdote/placebo/a bad study, etc.”
LOL – Me too! And you know what? I have found in the last year or so, since I’ve been visiting doctors a lot more due to this connective tissue disease (or whatever) that I have, it’s generally NOT helpful…meaning my “I could be wrong, anecdote, etc” qualifications just seems to confuse the conversation. I’ve vowed not to do it anymore.
It does seem helpful to jot down obvious symptoms on a calender. That way when a doctor asks how long something’s been bothering me I can say “two months” instead of umm, well I’m not sure, maybe it started last month? Since using this method, I’ve found I tend to underestimate these things.
That is the most helpful thing – write down key bits of information, symptoms, treatments and side effect. Keep a diary. But don’t overwhelm it with lots of information, just the important stuff. Don’t rely on your memory.
And (while I’m at it) – bring all your medication to your doctor visits, including supplements. And keep a copy of critical test results and bring them along too. If you have any chronic illness of any complexity, keeping a little folder or ring binder with symptom diary, medication list, and important study results is very helpful.
Don’t bring a novel to your visit, however, because that will dilute out the important info with extraneous info.
@Steven Novella – That is very helpful information for a patient. I try to keep my test results together in a folder, and keep a journal of symptoms (although deciding what to include or not is an evolving skill) but I have always thought that I would come across as a complete hypochondriac if I brought these things too a doctor’s appointment.
Having to visit doctors for multiple complaints (fatigue, skin complaints, flank pain, shortness of breath, joint/muscle pain) over a relatively short period of time, I already feel very aware of how very much I must look like a hypochondriac.
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Janet, I just went through that exact shoulder diagnosis process a few weeks ago and had the same issue. I know its been bothering me for a while, but I have no idea how long. Could be 6 months could be years. The problem was that the more I thought about it the more I risked modifying my memory so now I have absolutely no idea when it started.
My big issue is that I am fairly active so I constantly have injuries and its hard for me to remember which once had a slow gradual onset from overuse vs. which ones I specifically injured. I tend to ignore injuries because most are self limiting so I just work through them. But, then the occasional injury persists and I can never remember how it started. With my current shoulder injury I know I had an acute injury a few years ago but its hard to remember if that fully cleared up or if this is a remnant of that initial problem. Thus I end up making the same qualifications at the Doctors office as Janet & mousethatroared described. I think I’m going to start using your idea mousethatroared and keep a journal of my injuries.
Janet,
“I always dread the question: “So, how long has your shoulder (or whatever) been hurting?”
I confess I usually pull something out of thin air, and then immediately start revising it. Does this information actually help diagnose whether I have arthritis, tendonitis, or rotator cuff? Maybe she is just making conversation?”
I suppose if the pain started yesterday or a few days ago, she’s not going to be getting into a long detailed discussion about it or ordering any investigations or blood tests. You might just be after a day off work.
I made an explicit point of tracking some symptoms once (the healing time of cold sores using various medications, ointments and unguents). I was startled by two things – first, I had zero idea how long these things took; I had thought on the order of weeks when it was actually far less than that. Second, nothing seemed to make the cold sore go away faster (normally within 2 days at the most, it had withered) but applying pretty much anything to the wound let it heal faster and more comfortably (because it spent less time drying out, cracking and re-injuring the underlying tissues). So now I just apply generic lip balm with q-tips and I’m back to normal in about a week.
As an exercise in self-correction however, it was fascinating. I was genuinely startled at how off my estimates and memory were. Another time I had an injury to my abdominal muscle which never seemed to get better…until I really thought about what it used to be like (at one point I had to bend double to sneeze, and it still hurt).
It’s an exercise I think everyone should try once. A great way to confirm the failability of memory.
@WLU – Like you experienced with you abdominal muscle, one thing that I find very difficult to track is when pain diminishes.
Doctor’s often ask about morning stiffness and how long it lasts “Does it last for 20 minutes or over 1 hour?” But when pain decreases one doesn’t tend to notice it (particularly in the morning when most folks are busy). It’s usually when the pain increases that one notices it. So I can say “Yes I am less stiff in the late morning than early morning.” but give a timeframe in 20 or 30 minute increments? No way. I wonder who can?
I try to mark it to specifics. I remember having to double-over to sneeze, so I can anchor a specific degree of pain. I remember asking my mother to look at an injury in person, and I only happen to see her at specific times during the year. I try to test and remember range of motion for joints. I note which pants I can wear, and which ones I can’t, and when I could last wear them. Often all I can summarize is binary absolutes (definitely less than this day; definitely on this day; definitely fatter than the last time I wore these pants). The only time I undertook actual record keeping with any rigor was for the cold sores, but it definitely underscored how unreliable memory is. The absolutes, in addition to letting me note improvements or degradations, also confront me with this failibility, which in turn emphasizes how valuable it is to note those absolute.
I’ve never been asked the “how long does it hurt” question. If I were and it were important, I’d use a stopwatch or my cell phone
Only way to be sure, the human memory is utter drek.
nah – I’m not going to use a timer. I’m inclined to think that if it’s not obvious*, my subjective observations would be too unreliable to base any judgment on anyway. Better to move on to the next question.
*plantar fasciitis is obvious – you get up and the minute you hit your feet you say WTF!? – look at the clock when you stop hobbling.
This is why it is critical to give feedback to clinicians who initially missed a diagnosis.
Related: the doctor who makes a med change should be the one who can follow the patient long enough to appreciate what that intervention achieved.
Lots of people want to admit complex behavioral patients to residential programs or inpatient units to “have their meds adjusted.” I try to tell them that the doctor who knows them best and who will be with them for the next year or so should be the one to make med changes. But they look at me like I have two heads when I say this, as does the admissions department.
That is the most helpful thing – write down key bits of information, symptoms, treatments and side effect. Keep a diary. But don’t overwhelm it with lots of information, just the important stuff.
Tangential comment for the insurers out there: Please stop asking me to pay attention to stuff that is not relevant to my particular patient. Like making me do a substance abuse evaluation on a 13 year old non verbal autistic child living in RTFs the past 4 years. When you scare me into chasing after infos I don’t need for the sake of your computer database, my scare-o-meter goes off calibration. My natural “holy f_ck” reactions to things like a creatinine of 1.2 in a child on lithium doesn’t last long enough to make sure a repeat lab is done and reported in a timely fashion.
Also, dearest insurers, I recognize that you will be mining your big fat database to prove to state governments that nothing really works so my patients ought to be left to fend for themselves, wherever that may be. Please don’t be like that though.