Differential diagnosis and treating patients as individuals

I recently wrote about the importance of a differential diagnosis.  Today I want to assume that you have a definitive diagnosis and discuss how we deal with that illness.  First, some ground rules.

There are hundreds of medical texts and unlimited amounts of information on Google that help define an illness.  They all portray the “textbook” description of how the illness should present, what symptoms the patient should experience.  They all discuss what the treatment should be and how the patient should react to the treatment.  All the texts refer to the classic presentation of an illness that is affecting the average patient.

Ground rule number one is that the “average” patient does not exist.  In 27 years of practicing medicine, I have never met the “average” patient.  All of my patients are unique individuals who respond to everything in their own peculiar ways.

Ground rule number two is that patients don’t read medical texts so they don’t know how their illness should behave.  Instead, they have unique symptoms and findings that cannot be found in medical text.  It is as if they make up their own ailments.  The “textbook” presentation of an illness exists only in the text books.

Ground rule number three.  Illnesses are dynamic, fluid in nature.  They are forever changing.  Today’s symptoms and findings may well be gone tomorrow.  Tomorrow’s findings may change the diagnosis.

Ground rule number four.  The text book treatment for any given illness is often wrong for the unique individual who receives that treatment.  Since the PDR (Pharmaceutical Reference Guide) lists the benefits, risks and side effects of a medication based on the concept of an average patient; and since the average patient is a fictitious entity, one never knows how a unique individual will respond to any given treatment.

So, how do I make sense out of this seemingly impossible mess?    I treat my patients as individuals.  I do not expect them to behave like the masses.  I assess their symptoms and findings and find what I believe is the best treatment for their unique circumstance.  I know the initial diagnosis I make may be wrong or that the treatment may be inadequate.  I protect the patient by staying fluid and not anchoring to one diagnosis but instead keeping my differential diagnosis (refer to yesterday’s article) open.  I recognize that illnesses are fluid, capable of changing course and worsening.  I advise my patients that they should follow up in the office if anything changes or they are not getting better.  Follow up visits are essential for patient safety.

How does my patient know what to do?  My patients needs to listen to their own bodies.  If they are not getting better or are getting worse, they need to be seen.  My patient needs to understand the dynamic nature of illness and expect change.  My patients often tell me, “Doc, I’ve never had the flu.  I am healthy; I eat healthy and take vitamins.  I don’t want a flu shot.”  Staying “fluid” means recognizing that just because you have always been healthy and never had the flu doesn’t mean that you will always be healthy and never get the flu.  Staying fluid means that just because you have always had reflux and chest pain doesn’t mean that your chest pain will never represent a heart attack.  Please, don’t get so comfortable with a diagnosis that you miss a chance to make an early diagnosis of an intervening illness or a significant change in a current illness.  The life you save may be your own.

Stewart Segal is a family physician who blogs at Livewellthy.org.

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