Think before treating – diagnosis matters

I have spent significant time over the past week contemplating the teaching of internal medicine.  As I spent time, a loyal reader sent me this link – Spiraling Empiricism: When in Doubt Put on Blindfold and Shoot

As Congress wrestles with cost (and that is really the crux of health care reform: paying too much for things we don't need, and having perverse financial incentives to make us do things to patients that they do not need), this is the sort of nuance that does not get discussed. Indeed, the push for efficiency and "quality" has every hospital touting "pathways" and "algorithms" for the treatment of pneumonia. And with the focus on "outcomes" research we will probably be saddled with more pathways and algorithms. It is commonplace to see patients being wheeled down the "pneumonia" pathway and meeting all the quality and other metrics that measure a hospital's efficiency, only for me to disagree with the label of pneumonia. Diagnosis matters. Patients would concur, even if we seem to have forgotten.

This problem does not just occur with infectious diseases.  Let me list some examples that come quickly to mind:

1. Residents treating all hyponatremia with IV saline.  In at least one case, the patient had true SIADH and the saline caused the sodium to fall significantly.
2. Residents treating all elevated creatinines with IV saline – sometimes that patient has obstruction or ATN
3. A patient with known hepatitis C and ascites treated with spironalactone.  He actually had CKD and nephrotic syndrome, and then presented with hyperkalemia
4. A patient with acute elbow pain, swelling and fever.  The arthrocentesis showed > 120k WBC.  The resident made a firm diagnosis of septic arthritis.  The next day we found the correct diagnosis of acute pseudogout
5. A patient treated for recurrent non-resolving pneumonia then comes to our hospital where a diagnosis of PCP and HIV is made
6. Multiple cases of Lemierre syndrome where patients suffer needlessly because the physician blames everything on "just a sore throat"

In these and many other situations diagnosis matters.  Too often we see failure of diagnosis.  Too often I see excellent residents who make these mistakes through a reliance on empiricism.

I blame academic medicine for this problem.  Too few teaching attendings stress the diagnostic thought process.  Too many teaching attendings tell residents and students what to do, rather than why to do. 

Many factors are contributing to this problem, but I submit that the factors are really excuses.  We have an obligation to practice thoughtful medicine.  We must insist on the importance of thoughtful medicine.

I do not care about the bean counters and their performance scores.  I do not care about RVUs.  I do not care about pathways and protocols.  None of those inventions help us make diagnoses.  The cornerstone of good medical care is proper diagnosis.  As Verghese states eloquently – diagnosis matters.