Talking is king

Saturday, July 14, 2007

There may be nothing more frustrating than asking a professional for an opinion and receiving an ambiguous or less complete of an answer. Medicine may be one of the worst offenders since time is not only an aid in diagnosis; it’s also an ally in treatment.

The key to diagnosis is history; the story that the patient tells and the questions that the doctor asks to get the nuanced details. The art of medicine is to ask just he right question that holds the key to diagnosis. Tests may confirm or may lead the doctor and patient to the right answers, but sometimes those tests are of little help.

A broken scaphoid bone in the wrist is a good example of how x-rays may mislead. The diagnosis is made by history, falling on an outstretched hand, followed by tenderness and swelling in the snuffbox. This is a depression on the back of the wrist, at the base of the thumb, where two extensor tendons outline a divot when the thumb is pushed back. Just underneath the snuffbox lies the scaphoid. It’s a sneaky bone because of how it is oriented in the body and fracture lines can hide on x-ray. If the x-ray shows the break, great. If not, then the conversation with the doctor becomes frustrating for the patient.

“The x-ray looks normal, but that doesn’t mean you don’t have a broken wrist. I suggest we treat you in a cast for a week and then take another x-ray to see if the fracture shows up. If it’s broken, then we’ve treated you properly. If the x-ray remains normal and the swelling and pain goes away, then it probably wasn’t broken in the first place.

And sometimes even if it is broken and it’s treated with a cast, the scaphoid has such bad blood supply; it may not heal and may need an operation.”

A car repairman wouldn’t have a second chance at a repair if he admitted that he didn’t know what he problem was, whether his treatment was correct or even if it would work. Unfortunately the body has stranger wiring than even British cars and problems can be more difficult to pin down.

Using tests to pin down a diagnosis requires the doctor to balance what information he will get and what he will do with it. If the test won’t change the recommendations and treatment given to the patient, then perhaps the test shouldn’t be done. If it makes a difference, then by all means, go ahead.

Many patients want blood tests or x-rays, presuming that they hold the key to the diagnostic puzzle. I’m reminded of the sayings of my professors in medical school: if you don’t have the diagnosis after taking a history, go back and spend the time to talk to your patient again.

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