Diagnosis
A word that means many things, it is not always what it seems. A doctor may like to shoot from the hip in making a diagnosis. Existential in his thinking, to this shoot from the hip practitioner, a diagnosis does not exist until he makes it, and it becomes codified in his doing so. A preponderance of evidence is more than enough support for him. It is, indeed, cool to make a diagnosis from across the room based on a pattern of speech, a dysfunctional manner of walking or some telling body configuration.
On the other hand, there is the provider who cannot make a decision with sufficient evidence short of an autopsy report, the other end of the Briggs-Straten Scale. The point I make: medical diagnosis in the real world can be viewed as a moving target. Beyond reasonable doubt seems a reasonable standard, but it may be hard to know when that standard has been reached. A lot of water goes under the bridge before a reasonable diagnosis can be established.
Insurance both, private and government, on the other hand, may require a given diagnosis to justify certain tests. The requirement is thus for a conclusion, a diagnosis, preceding the very evidence necessary to make that decision! One may be tempted to suggest a relevant diagnosis in order to meet these requirements. The reality, however, may be an uncertainty with several possibilities. A true differential diagnosis may contain many possibilities. Such preemptive diagnosis is almost certainly wrong and wrong by virtue of the system. Furthermore, the payment for the visit or the admission may be withheld without a definitive diagnosis to justify the encounter, when again the diagnosis may yet be quite in doubt. Consider the case wherein the final judgment is of a very benign nature after extensive testing Would one leave the burden of costs upon the patient for these tests, which, indeed, were justified, or would one offer the “rule out” diagnosis to justify the testing? The agencies draw no distinction. These agency requirements amount to feigned and deliberate ignorance to the end of reaching an economic goal, a goal of delay if not denial of payment.
The trial lawyers pose another dilemma. Over the years, the concept of negligence has expanded to include failure to diagnose. In the past, an honest best effort error in medical judgment, failure to diagnose, based on the local standard of care and training of the provider was not considered an actionable tort. Today it is, yet diagnosis in reality is a progression. If that progression becomes interrupted for any reason, then there results implicit liability. Such an encounter may be followed by a later evaluation in which a subsequent provider can reach the diagnosis with ease because of further data or further symptoms due to the advancing disease process. It is said by public health planners that 2/3 of the time the wrong diagnosis is made by the first provider that evaluates the symptoms of a cancer patient. I am not surprised, due to the vague nature of early symptoms. Listing the differential diagnostic probabilities helps with the legal requirements for staying out of trouble but the full list may be troubling to the patient, and if the insurance company gets a hold of the differential, the patient may find him or herself un-insured.
Because of these distortions, any statistics based upon published medical diagnosis may be held suspect. Enthusiastic propositions for published standards of care or so called best practices may too be questioned. In these fixed protocols, a wrong diagnosis for any of the above reasons might lead to dangerously inappropriate but mandated treatments. In addition, as I have written before, these protocols freeze the diversity of thinking and the very skepticism responsible for medical progress.
None of this suggests that the physician is anything less than what you would have him or her to be in diagnostic acumen. The detective work remains a science. The truth emerges through an exciting series of revelations based on a carefully strategized diagnostic plan of attack. The physician, the diagnostician, applies science and art in one of the great endeavors of humanity. The administrative bureaucracy is highly destructive to this art.
On the other hand, there is the provider who cannot make a decision with sufficient evidence short of an autopsy report, the other end of the Briggs-Straten Scale. The point I make: medical diagnosis in the real world can be viewed as a moving target. Beyond reasonable doubt seems a reasonable standard, but it may be hard to know when that standard has been reached. A lot of water goes under the bridge before a reasonable diagnosis can be established.
Insurance both, private and government, on the other hand, may require a given diagnosis to justify certain tests. The requirement is thus for a conclusion, a diagnosis, preceding the very evidence necessary to make that decision! One may be tempted to suggest a relevant diagnosis in order to meet these requirements. The reality, however, may be an uncertainty with several possibilities. A true differential diagnosis may contain many possibilities. Such preemptive diagnosis is almost certainly wrong and wrong by virtue of the system. Furthermore, the payment for the visit or the admission may be withheld without a definitive diagnosis to justify the encounter, when again the diagnosis may yet be quite in doubt. Consider the case wherein the final judgment is of a very benign nature after extensive testing Would one leave the burden of costs upon the patient for these tests, which, indeed, were justified, or would one offer the “rule out” diagnosis to justify the testing? The agencies draw no distinction. These agency requirements amount to feigned and deliberate ignorance to the end of reaching an economic goal, a goal of delay if not denial of payment.
The trial lawyers pose another dilemma. Over the years, the concept of negligence has expanded to include failure to diagnose. In the past, an honest best effort error in medical judgment, failure to diagnose, based on the local standard of care and training of the provider was not considered an actionable tort. Today it is, yet diagnosis in reality is a progression. If that progression becomes interrupted for any reason, then there results implicit liability. Such an encounter may be followed by a later evaluation in which a subsequent provider can reach the diagnosis with ease because of further data or further symptoms due to the advancing disease process. It is said by public health planners that 2/3 of the time the wrong diagnosis is made by the first provider that evaluates the symptoms of a cancer patient. I am not surprised, due to the vague nature of early symptoms. Listing the differential diagnostic probabilities helps with the legal requirements for staying out of trouble but the full list may be troubling to the patient, and if the insurance company gets a hold of the differential, the patient may find him or herself un-insured.
Because of these distortions, any statistics based upon published medical diagnosis may be held suspect. Enthusiastic propositions for published standards of care or so called best practices may too be questioned. In these fixed protocols, a wrong diagnosis for any of the above reasons might lead to dangerously inappropriate but mandated treatments. In addition, as I have written before, these protocols freeze the diversity of thinking and the very skepticism responsible for medical progress.
None of this suggests that the physician is anything less than what you would have him or her to be in diagnostic acumen. The detective work remains a science. The truth emerges through an exciting series of revelations based on a carefully strategized diagnostic plan of attack. The physician, the diagnostician, applies science and art in one of the great endeavors of humanity. The administrative bureaucracy is highly destructive to this art.
posted by Clancy Hughes | 1/17/2005 06:03:00 PM
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