Letters from Maine

What is an “early and accurate” diagnosis?


 

For the last few weeks, the eye-grabber at the top of the American Academy of Pediatrics shopAAP email has been “Early and Accurate Diagnosis.” The unstated claim is that a practitioner who subscribes to one of their continuing education products will improve his or her chances of making an early and accurate diagnosis that “Also Cures Missed School, Soccer Practice, and Music Lessons.” The tagline, Early and Accurate Diagnosis, got me ruminating.

Dr. William G. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years.

Dr. William G. Wilkoff

What exactly is an accurate diagnosis? And how does one define an early diagnosis? These are not merely questions of semantics. An honest attempt to answer them scratches through the surface of some serious issues facing a primary care physician.

Who are the judges deciding whether a physician’s diagnosis is accurate? Should it be a panel of academic physicians, most of who are specialists and subspecialists, and who are most comfortable seeing patients with array of signs and symptoms that your patient has presented? Or, should it be a collection of your primary care peers working with limited resources miles away from a tertiary care center?

Is there such a thing as a diagnosis that is close enough? How often is it important that your diagnosis is spot on? Is it like a high school algebra problem in which you could get partial credit for showing how you arrived at the not-quite-right-answer? It really makes a difference only when you start acting (or, in some cases, not acting) on your diagnosis.

Let’s be honest. How often have you made the wrong diagnosis and the patient got better with your management plan? Your therapy may have worked for Diagnosis A even though you were targeting Diagnosis B. Or, more likely, the patient was going to get better without any intervention.

Don’t get me wrong. I think a correct diagnosis can be, and often is, extremely important, but it is really the patient who is the judge of whether you got it right. He doesn’t care what you called it. He is happy knowing that he got better and you didn’t hurt him.

Now, what about that “early” piece? Again, the patient might have something to say about this. You may have made the correct diagnosis but because your productivity is limited by a clunky EMR or your appointment desk does a poor job of triage, the patient was forced to wait an unconscionable amount of time to be seen.

A timely diagnosis certainly is important in many situations. But particularly, early in your career, you may not have the experience to make those quick one look and you’ve got it right diagnoses. These are times to come clean and tell the patient that you aren’t sure what they have. Of course, you might want to choose a better phrase than, “I don’t have clue.”

If I had been asked to write the AAP’s tag line, I would have chosen “efficient” instead of early. If you made the correct diagnosis and it was reasonably timely but you ordered a barrage of unnecessary and expensive tests that inconvenienced the patient, you should have done a better job.

Finally, if you make the correct and early diagnosis but deliver it to the patient poorly, your therapy may not work. Again, it boils down to being an artful and caring physician.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

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