Diagnosis or a Descriptive Explanation?
In an ideal situation every patient will have a diagnosis after a visit to an Emergency Department (ED), at least this is the mantra in Medicine. There are, of course, the uncertainty associated with medical diagnosis, the biases in clinical reasoning, the “zebras”
around, and the most important issue, the difficulty to give a name to a particular situation of a patient because his or her symptoms are common or they are not suitable to discriminate between several entities. Modern Medicine tries to be precise and to find the exact name for a disease, but this is not always possible in the real world. Then, what can we do? Patients need an explanation for his or her problem and a plan to follow. This is different to describe a situation, using a symptom as the diagnosis, the explanation must be based at least on an anatomical or physiopathological reasoning.
How many patients are discharged from an Emergency Department with the name of a symptom such as “lumbalgia”, “non-surgical abdominal pain”, epygastralgia”, without an explanation of the possibilities and some advices about “alarm sign”?
Describing the problem, explaining the possible etiology, establishing a follow-up plan, is an alternative when a particular diagnosis can´t be found. It is important to invest the proper time to be sure that the patient and the family understand the situation and to write a paragraph more than the usual line with the “clinical judgment”. The achievement of a “good” outcome to the patient means satisfaction for the own patient, for the family and for the doctor, and this is the result of a complex pathway of daily decisions, conversations and reasoning.
The conclusion is that we have to look for a diagnosis, the exact health problem of the patient, but, when there is no clear answer, we have to explain to the patient the range of diagnostic framework and how to be aware about the possible signs and symptoms that could give the clue to his/her problem.
Lorenzo Alonso. Foro Osler
