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It’s not that simple…

In many cases, it is not at all simple to diagnose accurately on a first consultation.

Many times diseases do not present immediately with a full picture, as clinical situations are not static, they change, they evolve and even when a first diagnosis was done correctly, according to the data that had to be considered at that moment, it might have to be changed later on.

It is not that the doctor made an error, as the patient could be led to conclude. What happens is that the initial assessment was pointing into a direction that, on follow up, did not prove to be the right one.

A doctor is not a witch … although we wish many times that we were… to foresee the future and never have to say, as we many times do, “I do not know exactly what is wrong with you, we have to wait for the evolution of the symptoms…”

The way a patient reports symptoms is extremely relevant as it is influenced by his or her cultural background, and depends on socially and culturally held conceptions of health conditions which, in turn, influence how the patient reacts.

The social perceptions of disease modify the ways a patient perceives and presents his symptoms. As a consequence, the physician can be misled into conclusions that are not wrong but are not right either … as only the future will prove.

The diagnostic procedure

The diagnostic procedure is the method by which health professionals select one disease over another, identifying one as the most likely cause of a person’s symptoms. Most times symptoms that appear early in the course of a disease are often more vague and undifferentiated than those that arise as the disease progresses, making this the most difficult time to make an accurate diagnosis. Reaching an accurate conclusion depends on the timing and the sequence of the symptoms.

In making a diagnosis, the physician, besides the symptoms given by the patient, also relies on various other clues such as physical signs, nonverbal signals of distress, and the results of selected laboratory, radiological and other imaging tests.

When in possession of all the necessary information, a list of possible diagnoses will be considered and by narrowing the list with appropriate additional tests, hopefully the final diagnosis will be established.

I said hopefully because it is not so simple, so straightforward, as when the patient does not progress as expected even after treatment has begun, the list of possible diagnoses will have to be revised, starting the diagnostic procedure all over again.

Diagnostic tests are not always capable of establishing the presence of a disease without doubt. They are part of the diagnostic procedure but they are not “the” procedure. It is extremely important to know which tests to order and that is why patients need a doctor requisition, following a clinical evaluation, to have complementary tests done.

Doctor-patient relationship

An important feature of diagnostic decision-making is the ongoing relationship between the physician and patient. The knowledge a physician gains in caring for the patient for a long period of time can provide greater insight into any health problem. When the symptoms are caused by emotional factors, the family personal physician is more likely to accurately diagnose them than is a physician seeing the patient for the first time.

Also, a lengthy and trusting association with a physician will often positively influence the patient’s outcome. Thus, sporadic visits to physicians who are unfamiliar with the patient and are asked to provide diagnoses and treatment without the benefit of this partnership are more likely to be inefficient, expensive and less personally satisfying.

Time is relevant

One of the most difficult tasks in medicine is to separate, in the early stages of an illness, the serious and life-threatening diseases from the transient and minor ones. Many illnesses will resolve without a diagnosis ever being reached. Nevertheless, an illness may remain undiagnosed for months or years before new symptoms appear and the disease advances to a stage that permits diagnosis.

Early in the course of a disease, decisions must be made with fewer clues to the diagnosis than are likely to be available later. Thus, if a diagnosis is not made immediately by a doctor, it does not mean that the doctor is incompetent or ignorant and that you need to run to every other doctor you can possibly find for a second, third or even forth opinion. If your doctor will need another opinion, you should trust him to find the right specialist for your situation.

My father, who was a physician as well, used to say that the last doctor a patient sees is always the best as he profits from the normal evolution of the disease and from all that was done before.

There are occasions when it would be wonderful to have a crystal ball … a really, really good one!  

Best healthy wishes,

Dr. Maria Alice

Consultant in General and Family Medicine. General Manager/Medical Director – Luzdoc International Medical Service. Medical Director – Grupo Hospital Particular do Algarve