Patients frequently ask me how I choose their tests and treatment. Tests, I say, confirm or exclude my clinical diagnoses. In addition, the result of a test should alter my decision making process for their care. I only suggest a treatment that will help them live longer, prevent something bad from happening, or make them feel better. If these goals cannot be achieved then there is no reason to get a test or begin a treatment. In this day-and-age of cost-effective medicine, where outcomes matter, this approach is essential to good patient care. Let’s look at this in detail.
Testing Goals
Different Body Systems Give Different Symptoms
Let’s take chest pain as an example. Many different things can cause chest discomfort. Examples include musculoskeletal pain; gastrointestinal distress or disease; pulmonary disease; heart disease; or even psychological problems such as anxiety. Pain from each of these body systems has very distinct qualities. For example, anginal chest pain, when the heart is not receiving enough oxygen, is a tight and squeezing sensation felt under the breast bone. Additionally, angina typically occurs with exertion and relieved by rest. Stomach ulcer pain is sharp and brought on or relieved by eating. Musculoskeletal pain is sharp, easily localized to a specific area of the chest and exacerbated by movement or touch, and relieved with nonsteroidal anti-inflammatory drugs and rest.
How The Medical Practitioner Decides What Test To Perform
Medical Practitioners learn these trends and apply them to make their diagnoses, to order tests and to prescribe treatments. For example, the practitioner orders an electrocardiogram (ECG) and a stress test for cardiac-type chest pain. A barium swallow is ordered for ulcer-like pain. The goal of ordering a test here is to confirm or exclude the practitioner’s suspicions. It makes no sense to order a rib X-ray for a patient with chest pain that is thought to be from a gallbladder problem.
Treatment Goals
How The Medical Practitioner Decides What Treatment To Prescribe
Once a diagnosis is confirmed, the Medical Practitioner then chooses a treatment. This treatment should make a patient feel better, lower the likelihood of something bad occurring, or decrease their likelihood of dying. For example statins (a type of cholesterol-lowering medication) decrease morbidity and mortality in patients that are high risk for heart attacks or strokes. Aspirin helps people live longer or be less likely to have a heart attack in patients with known coronary artery disease. In patients without known coronary plaques, aspirin may not help and cause more side effects than benefit.
Summary
Medical practitioners are detectives. They listen to the clues, make a preliminary diagnosis and then decide on tests. Tests confirm or exclude diagnoses; this is their purpose. Once a diagnosis is confirmed then treatment is suggested. The purpose of treatment should be to help someone live longer, reduce their risk of something bad happening, or make them feel better. If one or more of these cannot be accomplished, then there is no reason for that particular treatment.
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