After reading one of the editorials in the February 14 edition of Statler and Waldorf entitled “Health Center Misadventure,” I was left confused. Even though I was not involved in this particular case, as I read the progression of care I thought that the case described by the author had been handled exactly as a medical provider (physicians, physician assistants, and nurse practitioners) should have handled it. The author on the other hand felt that her case had been mishandled. How could it be that we have such different views of the same events?
I believe the basis for many of these patient-provider misunderstandings is a disconnect in the understanding on how diagnoses are arrived at. Many patients are unfamiliar with how providers actually come to a diagnosis. Many are still under the impression that providers should always be able to come to the exact diagnosis the very first time they see the patient and that there is a specific test out there for every possible diagnosis. We providers wish it were this simple, but it is not. Coming to the correct diagnosis in primary care is usually more of a process than an “aha” moment.
When we as providers are trained, we are taught that unless someone is in critical condition, that we should avoid immediate testing and use the history and physical exam to arrive at a working diagnosis (sometimes called a presumed or provisional diagnosis). The working diagnosis is arrived at after considering the differential diagnosis (a list of all the possible diagnosis) and choosing the one that fits the patients’ symptoms the best. The working diagnosis is then confirmed or refuted by follow up testing or by observation of the patients’ symptoms over the next few days (similar to how many scientific theories are supported or refuted). The only exception to this is in the emergency room, where over testing and over treatment is the rule, as ER providers do not have the ability to monitor a patient over time via follow-up visits like those of us in primary care. This is one of the reasons why routine care at an ER is so expensive and discouraged by most insurance companies and physicians.
Coming up with a working diagnosis for many of the common viral infections that happen on a college campus (influenza, mononucleosis, coronaviruses, rhinoviruses, and adenoviruses) can be extremely challenging early on, as all of these can have the same exact symptoms in the first two to four days. Rarely are any of these diagnoses life-threatening in a college population, so providers are taught that symptom observation for several days is the best path. Over time it becomes easier to figure what specific tests, if any, should be done to help us confirm or refute our working diagnosis and get to the correct diagnosis.
Now with the above understanding of how diagnoses are made, let’s use mononucleosis as an example. Providers know that the mono test almost never turns positive before days five to seven of the illness. So, why do a test that you as a provider know will only cause discomfort and not get you any closer to the confirmed diagnosis? The answer is providers shouldn’t do a test during this period. Instead we explain to the patient that tests are unlikely to be helpful at that point and suggest supportive treatments and observation (unfortunately, there are no cures for mono or the thousands of other viruses that can cause similar symptoms). At the end of these initial visits for a viral illness, providers should make sure that patients understand that they should come back and tell us if their symptoms are not progressing as we expected based on our working diagnosis. If symptoms are not progressing as expected and the patient comes back and relays this to the provider, the provider should then reevaluate and possibly then proceed with testing or at least a different working diagnosis.
Back to the Statler & Waldorf editorial; if we at the Health Center did not explain well enough how working diagnosis are used and why tests are not always done at a first visit to the author when she was in, then I would like to offer a public apology. We make every effort to cover these issues as well as give a time frame for follow up if the patient is not better, but there may be a time or two when we miss this. I also think that the authors’ conclusion that she should always question a provider’s diagnosis is a wonderful idea. Questioning a diagnosis should lead to a healthy discussion of how the provider arrived at the working diagnosis and even how to recognize if the working diagnosis is incorrect, as well as suggestions on when to follow up.
I would like to ask all students and patients to work with us toward developing a provisional (or working) diagnosis rather than declaring us neglectful when we are not 100 percent correct with our first diagnosis. Patients who have the expectation that medical providers are going to be 100 percent correct every visit are setting themselves up to be very frustrated by many of the medical interactions they will encounter during their lives. Please remember that medicine is a science and far from a perfect science. Just as other scientific theories must be supported by data, observational or empiric, so must a working diagnosis.
The very last thing I would ask of every student is that if you have an issue with the Student Health Center, please bring it directly to us. We always are willing to meet with students and hear their concerns. We are more than willing to change our procedures to serve students better if necessary.
Student Health Center