Being healthy is relatively easy; that is what your body does by default. It is capable of fulfilling this without extraordinary help when things are OK. However, when you get sick or out of balance, especially if you are not well for a long time, coming back to health can be very difficult. Treating diseases and these chronic imbalances are the domain of the medical doctor. The first and most important process that allows a doctor or any health care practitioner assist you is to make an accurate diagnosis of your problem. A doctor determines the likely causes of a disease; an acupuncturist diagnoses imbalances in meridians or structural function associated with pain; a nutritionist diagnoses possible imbalances in diet in relation to weight gain or optimizing energy and vitality, and so on. Ultimately, we are all in this together. But I would like to talk the short cuts doctors or any practitioner can take sometimes; why we do them and what that can mean to your treatment.
As a young medical student I heard a lot about “clinical thinking and reasoning”. It was the most important skill a doctor acquires. One important reference was “Harrison’s Principals of Internal Medicine”. It has an entire chapter covering the decision-making process, addressing this very dilemma of identifying the problem early and the need to investigate thoroughly. A doctor must quickly reach the best diagnosis – this is a central and critical first step before starting a treatment. Achieving the “correct” diagnosis at all costs early on can be prohibitively expensive and indeed unnecessary. In the practical and real world of medicine, doctors make good guesses based on statistics, affordable first treatment trials, and their personal experiences and intuition, while monitoring the patient’s progress along the way.
Medical diagnosis is not easy. Although many common diseases can be diagnosed easily after a brief examination or a few simple blood tests, less common conditions or serious problems can be masked. They can often present themselves as common, less serious issues, and thus be more difficult to recognize. In these cases process can be delayed by months, sometimes enabling the disease to become much worse before the proper diagnosis is made and the appropriate treatment is given.
The use of cognitive “shortcuts” or “rules of thumb” (also called heuristics) is very common in medicine and all professional practices. These short cuts represent a systematic, either/or flow chart of decision making. This is what most family doctors will do when they see a patient for the first time for most common health conditions. A more experienced doctor tends to be more comfortable with this type of approach, since the subtle non-teachable details he or she learns in practice over time do play an important role. It also helps if a doctor is more familiar with a given client or a given condition. Yet sometimes short cuts can result in an unnecessary incorrect conclusion. As most patients have experienced, within a few minutes, a doctor can often reach a conclusion to prescribe a drug, without touching you. But this is where big mistakes can be made if a more thorough investigation is not done routinely; there is the potential to miss a more serious problem.
Serious conditions can sometimes go unnoticed easily. Many different diseases start with similar milder symptoms (eg common cold and micro-embolisms in the lung), and only after a few days or a week, will look more serious. Not only do these conditions not resolve themselves, but additional classic and definitive patterns may appear on later- for example, a sudden sharp, pain in the chest, with shortness of breath, with no physical accident to explain it. This problem may not be picked up early without more thorough investigation. Thorough investigation can reveal the difference between something serious (but masked) with something not serious, self limiting, and not requiring treatment.
This is why a doctor is taught to always say, “come back in a few days if this does not improve or if it gets worse.” This “wait and see” method is a key part of the diagnostic process, since it is less expensive and more practical than throwing all the resources at a problem in the beginning. Furthermore, beyond the prohibitive costs, it can be very stressful on patients if the doctor investigated remote possibilities right away. For instance, a doctor does not investigate cancer, for instance, every time you came in with a pain that was unexplained (even though this possibility is always in the back of your doctor’s mind, albeit remote).
If a patient responds to a particular drug positively, the diagnosis may be confirmed and hopefully condition has been correctly treated. However, a positive response to a treatment cannot be seen as a conclusive confirmation of diagnosis, especially if the symptom alone was treated (ie pain medication, acid inhibitors, high blood pressure medications). Therefore, ideally the diagnosis and the subsequent treatment plan should be reevaluated periodically, to confirm or better understand the nature of the symptoms as they progress to understand the nature of the problem. It is common that treatments can sometimes cover or delay the deeper understanding of the causes of symptoms; especially in issues of pain (eg cortisone shots may mask and delay the undergoing healing of a joint problem).
Another possibility is when a patient has a rare disease, especially if this is combined with a doctor who never has personally treated or seen the condition. The default tendency is to see it as a common case. Interestingly, students or new, resident-doctors often have great beginners “luck” with these sort of rare cases. They sometimes even perform better than a seasoned, older physician. This is because students see a common condition and a rare condition with a similar amount of novelty and investigation. They usually perform a more thorough examination since they haven’t yet developed their own short cuts.
Experienced doctors are usually more efficient to come to an initial diagnosis about a patient’s problem — they support their ideas through lab tests and diagnostic imaging accordingly. If they fail with their first idea, they will develop a new one and start investigating again to check different possibilities. Effective doctors are able to keep in mind a complex list of possible diseases that could explain the patient’s signs and symptoms, and then to list and simultaneously consider or investigate these possibilities. This is also why when a patient is referred to a specialist, a new potential problem is created. Although the specialist is very familiar with his/her domain, he or she does not always possess the bigger picture of possibilities for the problem; instead he or she often investigates in a biased manner within the framework limitations of his or her own specialty. Furthermore, this process is not well coordinated or communicated among different specialists, and can slow down a proper diagnosis and treatment. Unless a problem is deemed medically urgent, long delays to see each specialist can create even more problems.
In the end, there are no real short cuts when it comes to health. Most short cuts are usually the result of the need for efficiency, in how each practitioner spends time to diagnose, how we have limited diagnostic resources to use in our healthcare system, and in how the system has efficiently divided itself into specializations. Understanding the need and nature of these short-cuts can help us as clients or patients – if we are not getting better we need to go back to our doctor with doubt and questions; we may need to get a second opinion; we may need to try another specialty or practice. This is as applicable to medicine as it is with acupuncture or massage or any other professional domain where a healthcare professional is trying to resolve a problem.
Ultimately the client is the general contractor and the one responsible for the project of his or her health. Compared to the doctor or team of healthcare practitioners, he or she has more motivation, more subtle information regarding the body giving continuous feedback (pain, energy, or other symptoms the practitioner simply cannot measure), and more ability to coordinate and communicate the information among all the team. This is one short cut we should not take – the one where we give the responsibility of our health over to others.