There has always been a gap between what patients expect from doctors and what a doctor’s role is to help them. Patients want to know what is going on and get relief from suffering. In desperation, it is common to hear people demand of their doctor, “I came in to get an X-ray, a blood test for abc or an antibiotic.” This is not a doctor’s job, i.e., to do what you ask for and follow your orders.
If you see a doctor who does what you want without question, beware. Making assumptions instead of engaging in a deep and broad inquiry, even for seemingly simple issues, is not appropriate. You are not being given adequate consideration, which could result in outcomes both dangerous and life-threatening. It is bad medicine.
How dangerous? Here is an example: You are 60 years old, coughing and come in asking for codeine cough syrup. You just had a cold and the cough won’t go away. Your thorough doctor would want to know all about this cough, ask a lot of questions that might not make sense to you. Then he or she would do a physical exam that should at least involve the upper respiratory tract (nose, throat, mouth and neck), lower respiratory tract (lungs), heart and legs to assess for swelling. If all is benign, meaning no serious warning signs, you might leave with a prescription for cough syrup and a follow-up appointment in 6 weeks if you are still coughing. The follow-up is critical. Why? If you are still coughing in 6 weeks, this should not be ignored. A deeper dive into your overall health might be indicated, as well as a chest Xray and lab work. Chronic coughs can be signs of lung diseases, heart diseases and cancer at worst and pneumonia, medication side effects or sinusitis at the least, all of which don’t just go away with cough syrup.
Whether you seek care with a traditional doctor, NP, PA, ND or acupuncturist (i.e. Chinese medicine practitioner), it doesn’t matter. The approach should be the same. For the purposes of simplicity I’ll just use ‘doc’ and him or her.
Here is what a thorough evaluation entails:
1 Finding a DIAGNOSIS based on ‘the presentation’ (also known as your ‘symptoms).
Your job as patient is to tell your doc everything that is not right for you; only you know that and your doctor needs to hear it all. Don’t withhold anything, even if it seems trivial. You’re tripping and falling; don’t forget to share that your right toe is getting numb. Who would have thought having impaired taste would be such an important diagnostic symptom?! A good doc will take the time to listen because she needs all the facts to develop what we call a differential diagnosis (DD for short from here).
Next, expect the doc to do an examination based on what you have told him. It might be looking at your throat or doing a pelvic exam. It depends. But for most presentations, an examination is an important diagnostic addition to your story. Your doc finds the ‘signs’ in the exam.
Now your doctor has developed her DD – a list of possibilities of what might be going on based on what you are ‘presenting with’ (your symptoms and signs). Developing a DD is what a good doc is thinking about when he sees you because without that, the following steps are sloppy, unthorough and risk over-testing and errors in treatment plans.
2 Diagnostic tests based on the DD
You don’t need every test in the world. A good doc will glean which tests are needed to confirm or refute the possible diagnosis of what is ailing you. She will choose tests for exactly what you are presenting with. These could be blood tests, x-rays, special studies, CT, MRI. Lack of a comprehensive DD due to inadequate experience, training and time may lead to unnecessary tests and referrals in an already expensive healthcare system.
Sometimes your doc will suggest no tests, having a confident idea of what ails you, and will propose and prescribe a treatment plan. Treatments can range from: staying home and resting (also known as ‘tincture of time’ ) to blood pressure medication, physical therapy, etc.
3 Confirmation of diagnosis and putting together the whole picture
If tests are needed, this may take time. Be patient. Be sure an appointment is planned to discuss the results.
4 Treatment Plan may be offered on visit one, follow up or after tests
5 Follow-up and ongoing care, support and monitoring
After this first series of steps, they may need repeating depending how you respond to treatment. Trial and error is the name of the game, even in the scientific discipline of medicine. I used to tell my patients that I knew enough to suggest what might be expected with such condition and treatment, but I did not have a crystal ball to read the future. Every person is unique in their response to illness, treatment and recovery, even in something so simple as a common cold. This is (one of many reasons) why I object so strongly to protocol medicine.
This is why follow-up for everything but the most benign health issues is important. For instance, in every encounter with my patients, I asked them to reach out if their experience was unusual, unexpected or not helping within whatever time frame one would be expected to recover. I am aware that this important piece of teaching is missing in many healthcare encounters in 2023 where everyone (and especially the docs) are too busy. They are overscheduled, doing menial tasks (such as inputting orders and typing notes) which steal time from the important ones which require time to think, consider, research and communicate with you.
Some important questions you might expect and best be prepared to answer on a follow-up visit are:
In 2023 what could be missing in healthcare that makes it even more important to advocate for yourself?
Now you know what good thorough healthcare should look like. Now you know you are a unique person. Being pigeon-holed into protocol is not the best care. Now you know what is missing. When you note your encounter is missing any of these key parts, you can now advocate for what you need -- or find the right doc for you and what ails you. That’s our topic for the next column.
Debra L. Glasser, M.D., is a retired internal medicine physician who lives in Olympia. Got a question for her? Write drdebra@theJOLTnews.com
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