Diagnosis

Medical diagnosis as an art, a scientific detective game with all of the surprises and quick turns of a good mystery, may soon if not already, become a thing of the past, a lost art. Not because of genomics or molecular biology, but because of mandated guidelines for reimbursement. A physician considering a diagnosis and treatment faces the requirement of listing an appropriate diagnosis to justify the diagnostic testing, procedure or even examination of the patient. If everything is obvious the requirement does not cause a problem. Tests if any are done to cover the unexpected, for conformation or for medical-legal reasons.

However, things are never that simple. It is not at all uncommon for a patient to approach the third physician still attempting to resolve his or her problems, a diagnosis that has not yet been identified. One of the earliest tenants of differential diagnosis is to look for one diagnosis to explain multiple problems. If doing so requires appropriate testing procedures, looking for the layers of underlying factors, there is no way to offer an appropriate diagnosis to justify the tests without picking one that may or may not be close to, what’s going on. More likely the choice will be the most reimbursable alternative. There you have it; before you even get started you have the wrong diagnosis on the books and in the insurance system. In other words the rules of HICFA and aggressive insurance companies reward a snap judgment and penalize careful systematic differential diagnosis. The later usually costs less in the end.

I watched the debates last night and both candidates base their solutions on insurance companies with rate limiting guidelines and mandates. In my view neither proposal will work. There needs to be a return to academic medicine at the state level supporting a public alternative for health care, and -- let it compete with the private sector’s insurance based system.

The science of medicine advances with such speed and with such unrelenting change that any guidelines or algorithms become obsolete by the time they are distributed, and these changes do involve genomics, molecular biology and a bit of quantum physics.