I subscribe to this podcast, and when this one came up, I thought… “GOLD!” This will make my next blog post!
Okay, so, I took notes when I listened. I really wanted to add in my own commentary along the way, but I didn’t. Maybe that can be a future blog! So, hang onto your shorts, here are my notes from this podcast.
IS a diagnosis is important?
Sometimes yes. (i.e. to tell someone what it is and what it isn’t.)
Sometimes is guides prognosis and treatment.
Communicating with other practitioners.
Justifying treatment funding.
When is a diagnosis less important or even unhelpful?
- In the case of Overdiagnosis: i.e. labelling a person with a diagnosis that would, if left unknown or untreated, cause the person no harm. In such cases, you create a ‘new diagnosis’ by medicalizing ordinary life experiences (i.e. Degeneration, inflammation, muscle soreness).
- Does the pain or condition have an Insidious onset versus an acute injury?
This is important as part of the diagnostic triage. (i.e. Is it a specific diagnosis, a non-specific diagnosis, or a red flag diagnosis). These tend to be medically accepted worldwide, and most physios have training in these concepts. Questions to ask and things to think about:
1. Has there been a specific incident or injury?
2. Has there been a specific trigger? (i.e. a period of overload, or ‘getting up out of a chair’)
3. Insidious onset?
Acute cases make more sense to be able to make a specific diagnosis. However, does the case make sense to be a simple (treatable pathology) but of longer duration? (i.e. A frozen shoulder, a tendinopathy, nerve root inflammation). When cases don’t make sense and the signs and symptoms don’t add up, THEN, the pursuit of a specific diagnosis via advanced diagnostics can and should be advised.
Communicating and phrasing of certain diagnoses is important as well. Diagnoses such as “Impingement” or “Degeneration” could lead to problems of catastrophizing and a sense of inevitable pain or irreversibility of symptoms. It is therefore more detrimental to hear a diagnosis such as these, or at least to hear these without a further qualification that these diagnoses are not insurmountable.
When multiple interventions would be needed to confirm a diagnosis. (i.e. Shoulder impingement which can be managed conservatively versus bursitis which might require additional diagnostics and interventions.)
Does the patient need or want a diagnosis? Or just relief from pain?
You say, “Let’s settle down your shoulder after you were pruning trees all last weekend.” But the patient says, “What do you think it is?” Then the phrasing could be along the lines of, “Well, it could be just an impingement, or perhaps you’ve irritated the bursa.” So, instead of ‘labelling the pathology, you are addressing the symptoms and one of a handful of probable diagnoses, without sending the patient down multiple paths to obtain a specific diagnosis or catastrophizing what is wrong.
Alternately, you might need to provide a more pathology based diagnosis to control some patients from doing things that could irritate structures and delay recovery. (i.e. think runners, or sports enthusiasts). You can learn this in your assessment and/or by working with the patient for a couple of sessions.
Think about patient-centred care! What does your patient need to hear?
The other times you need a diagnosis.
Will the diagnosis impact your management?
i.e. Do you suspect a stress fracture? A ruptured Achilles tendon? Rheumatoid arthritis?
Is the problem Back Pain? Then no!
For most non-traumatic shoulder pain? No!
Some things to also think about.
Will Medicalizing the diagnosis cause the patient psychological or financial harm?
Sometimes you need to specifically NOT medicalize the diagnosis, (i.e. “You’ve clearly irritated your nervous system, and we just need to calm this down.” vs “You have a compressed nerve due to degenerative disc disease.”)
Sometimes you need to listen to the whole story and factor in other equations that could have a potential to sensitize the central nervous system. (i.e. “You’ve said that you aren’t sleeping well and have been working extra hours. Those factors might play into why your back has flared up.”) So, it’s important to review more of the history.
The initial consult should be long enough to get a full picture by listening to the patient. Sometimes it requires a session or two.
I found this blog very helpful, in that is summarized quite well how much physiotherapists think and approach cases. I think it’s a new way of thinking for some veterinarians, or rather, a new way of thinking for some younger veterinarians. I do believe that many of the older vets and vets from countries where people tend to spend less on their animals (at least from those I’ve chatted with over the decades), do approach diagnoses in the same manner as described above. I hope others find the commentary interesting as well, and I’d love to hear your feedback, so feel free to drop me a line!