Enjoyed my chat with Elizabeth Millard @Emillard_Writer and @SharecareInc about Health Screening. Preventing disease and finding it before it can harm you is one of the things I like best about being an #Internist @NYULangone
To the contrary, I think it can make me better at what I do. I already strive to get to know my patients, understand how health or lack thereof fits in the rest of their life. We discuss risk for future disease, concerns about hereditary and what medicines are best for them. That is personalized medicine. Getting to know my patients at the genetic level can only strengthen that bond. Using the information we get from genetic testing and putting it in the context of the person sitting across from me is how we put the Personal in Personalized Medicine.
The path to wellness begins with a proper diagnosis
It was a typical Monday for an Internist – lots of phone calls, catching up on results that came in over the weekend, a full office schedule. I was about to go see my next patient when my assistant said that Dr. X was on the phone about a patient, could I take the call. I popped into my next patient’s room and told them I’d be 2 minutes – they said no problem and I went to my office to take the call.
The call was from a sports medicine fellow working with a specialist that I’d sent Mr. Smith to (name changed). I met Mr. Smith about 2 months ago, he had new onset high blood pressure and complained of back pain. We’d started some blood pressure medication and he was seeing the sports medicine specialist to design an exercise program for his back. He’d gotten an MRI as part of his evaluation, and instead of showing the expected herniated disc, it showed metastatic cancer – from where, we did not know. We called Mr. Smith and had him come in the next day to review his scan.
I met with Mr. Smith and his wife the next day. I took them through the scan findings, explaining what we could and couldn’t tell. He told me his back wasn’t too painful, and the specialist was helping manage it. We talked about a plan – blood tests and CT scans to find the source of the cancer. I told them I’d speak to an oncologist – and arranged his appointment with him.
Two days later, I had the blood work and his CT results, and we met again. The news was not good – there were extensive metastases in his spine and it looked like lung cancer – though we still couldn’t be sure. I sat with the Smiths, and we discussed a plan. They’d be seeing the oncologist in a couple of days, I’d already sent there results over. We discussed the next steps, what the oncologist would likely do next. We talked about how he hadn’t been sleeping well, and that I could help with that.
The Smiths left – and I was drained. It was very emotional telling someone who felt fine they have metastatic cancer. Yet we both left the encounter optimistic. The Smiths understood they have an uphill battle, but together they felt informed, guided and supported.
How Mr. Smith does is mostly out of my hands – yet I know I played a huge roll in getting them ready. I did all the things I love about medicine – bonded with a patient, made a diagnosis, educated them and got them ready for the next steps. This is Internal Medicine, and why I do what I do.
You go to see a doctor with a painful shoulder. You tell the doctor that you can’t sleep because of the pain, and the doctor starts to make assumptions about your symptoms. Before you get a chance to tell the doctor your story, you are told you slept on it wrong, and given a prescription for anti-inflammatory medication. You don’t really improve and so you see another doctor for a second opinion. A full history is taken, and you tell the doctor that you play softball on the weekends and you collided with the catcher while trying to score. The doctor examines you and tells you that you likely have separated your shoulder. An x-ray is ordered and it shows a shoulder separation.
Unfortunately, quick, easy answers and assumptions frequently lead to an incomplete diagnosis or a misdiagnosis. These carry costs – your time and your money spent finding the correct answer, but more importantly, your health – which is why you go to the doctor in the first place. Your story is like a puzzle, separated pieces that depict your diagnosis – the doctor has to put them together.
Your doctor needs to ask the right questions and listen to you to put your puzzle together. It is what I am trained to do – make a diagnosis. But what is a diagnosis?
A diagnosis is a term with medical meaning. It is comes from a physician’s synthesis of a patient’s symptoms, history, physical findings and laboratory findings. A proper diagnosis is essential to begin a journey towards Wellness!
How does a doctor approach making a diagnosis? We start by making a list – called a “differential diagnosis.” As we take a history from a patient we start listing diagnoses that fit the symptoms. As more of the story unfolds, the list is adjusted, the order is changed, items added and removed. Then we examine the patient, and again revise the list based on our findings.
Tests are then ordered to do two things.
The approach to testing, however, doesn’t always focus on the most likely – there are other factors that determine the order of the tests. If being wrong about a diagnosis has severe consequences, it may be tested for first even if less likely.
Finally, all the information gathered from the history, physical and diagnostic testing are put together and the list is put into a final order and a diagnosis is made.
If a treatment works, it confirms the diagnosis choice from the list. If a treatment doesn’t work, the list needs to be re-examined and the history revisited to see what information was missing or not emphasized. This is a crucial time in communicating with your doctor – they need to know what you are experiencing. Based on that re-evaluation new tests may be ordered to further refine the list, and so on, until the final answer is revealed.
First and foremost it determines treatment. A diagnosis of Strep Throat requires treatment with antibiotics; a cold does not.
The diagnosis is what is used by insurance companies to approve tests and medications.
Diagnoses determine life insurance rates!
A diagnosis represents the last piece of the puzzle being put into place; it allows you and your doctor to chart a course of treatment and find direction after the confusion of not feeling well.
Without a proper diagnosis, you wander in the medical field, so remember:
The path to wellness begins with a proper diagnosis
As you sit in the doctor’s office for the first time, your eyes note the array of diplomas and plaques on the wall. You have never met this doctor before, but your friend said they were good, or you picked them out of a book, or you were referred by another doctor, and you are about to share intimate details of your life with them. You have questions about how you feel, and you are going to get a diagnosis. But who is the person behind the plaques? What do all those fancy diplomas mean? After all, they call the person who finished last in the medical school class the same thing as the first – “Doctor”. Doesn’t it make sense that you know something about this person who is going to ask you personal questions and examine you? Shouldn’t you know more about this person you call “Doctor”? Well, I think the answer to this question is YES! So who am I? Keep reading…
All doctors are trained to make diagnoses, some within specialities – orthopedists, neurologists, surgeons, etc. Most diagnoses are first evaluated by a primary care doctor. There are several specialities that make up primary care doctors – who you see will depend on age, who practices where you live and possibly your gender. Examples of primary care doctors:
So what is an Internist? The ACP defines it as:
“Internal Medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment and compassionate care of adults across the spectrum from health to complex illness.”