Under Diagnosis

Even when we have the right diagnosis, the underlying cause is often ignored. This is a trend in part driven by economic expediency and the over simplification of practice guidelines. Better to just call it congestive heart failure, CHF, and forget the meriode of complex causes. The same can be said of valvular disease, arrhythmias, chronic kidney failure etc. How many times do we change the acronyms and theories of pathophysiology?  As we discredit each theory, we replace it with another one on equally shaky ground. Does obesity cause diabetes or does diabetes cause obesity? Does sleep apnea cause cardiovascular disease or does cardiovascular disease cause sleep apnea? When you cannot find anything wrong with the complaining patient, is it in her head, or is she suffering from environmental and genetic factors that are pulling her apart? Who is to say that the controlled study today is any better than the one done in the fifties?

Medicine is on the cusp of a breakthrough in knowledge. Genomics and proteinomics offer new understanding of etiology that will change much of what we think we know.  Even then, the theories will be a moving target. No wonder, faced with these vagaries, those who would presume to write standards of best evidence look for the four-digit diagnosis.

Disease is a mal adaptation to the environment. If you look at it that way you open a Pandora’s Box of considerations, but that is the art of medicine. If we continue to promote simplified guidelines for diagnosis and treatment, we reduce the physician to a technician. There are those who consider such standardization a good thing from the viewpoint of highly efficient industrial practices. One has to ask one’s self, can medicine be privatized and run like IBM with industrial standards of efficiency and performance, or does the patient suffer from an over simplification?

I want my doctor to open my Pandora’s box looking for all the underlying causes.