Sunday, September 20, 2009

The Art of Diagnosis

Money Makes The World Go Around

While waiting on someone to complete their shopping today, I listened to The People's Pharmacy on National Public Radio. The subject was "The Art of Diagnosis" and the guest was Dr. Lisa Sanders, an internist at Yale University that in addition to being a physician writes a column for the NY Times and is a consultant for the TV show "House".

Dr. Sanders stated that many diagnoses were guesses, using the law of probability to start with the most common and then parse down to the less common if the most common did not work. For some of us who have gone through the guessing game more than once it is gratifying to know that what we felt - this is just an educated guess - is true. She said doctors needed to be more open about how they come up with a diagnosis and what the alternative (or less likely) guesses might be if the first one doesn't work out. She also stated that all patients have a story to tell, and many diagnostic errors occur when the physician or the medical establishment fail to pay attention to the story.

When I was trying to find out what had happened to me when The Headache began, I ran into many different physicians and many different diagnoses. The first was migraine, then status migrainosus, then migraine aggravated by sleep apnea, then intractable migraine, then medication overuse headache, then cluster headache mixed with migraine, then a cluster headache variant, then transformed migraine with occipital neuralgia, then paroxysmal hemicrania, then chronic cluster, and finally the only diagnosis that has really fit - hemicrania continua.

Almost every time I was interviewed I was asked "When did this headache start?" I would answer "December 2007" and the reply would be "I mean THIS specific headache" and I would answer "Since December 2007 - one nonstop headache" and then I would be ignored, and more expensive tests or drugs would be ordered. I guess because I had a documented history of migraine the doctors were going with the most probable diagnosis, but the last physician I saw actually listened and said - "One headache - this has been one headache this long?" and gave me the hemicrania continua diagnosis. She didn't need any tests, xrays, sleep tests, or hospital stay to diagnose this either - she just needed to listen, and apply her specific knowledge.

Having worked in healthcare and around healthcare for 20 some years I have a cynical attitude about healthcare entities and their primary motivation for doing anything: MONEY - either making more, or spending less. There are exceptions, and I have been around a few, but healthcare is big business in this country and has concentrated a lot of wealth in few hands. I don't see this changing anytime soon. Nor do I see any incentive for physicians to be better diagnosticians - value is not being placed on this skill, value is being put on the amount of time spent with each patient, i.e. more time = less money.

Hoping for a better world, knowing I probably won't get what I wish for!


  1. Your list of diagnoses made me laugh a little. Mine is only half as long but just as redundant and vague. :p

  2. Stephanie:

    I think I even missed a couple in there somewhere, and I didn't even count the ER doc's ideas! :)

    We need some kind of scoreboard for headache doctors to look at at in a glance so you don't have to say "been there - done that - doesn't work" everytime you see one.