“We were always taught that 90 percent of the diagnosis in medicine was based on what the patient tells you,” said Kenneth Polonsky, dean of the Division of the Biological Sciences and the Pritzker School of Medicine. “There are tendencies on the part of physicians to rely more on technologies than on what the patients tell them, their interactions with patients, and what they learn at the bedside.” Rebuilding the doctor patient relationship
The worlds of both conventional and complementary medicine are peppered with “machines that go ping”, as Monty Python would say. As patients, we have a fascination with tests, not just for the purpose of diagnosis but I suspect they can also validate our desire to be special.
From my two decades of clinical practice I have to concur with Dr Polonsky regarding the importance of listening and observing. Time spent face to face with a client is irreplaceable. Even when a patient doesn’t know what is wrong with them, they always hold the clues. It’s up to us as practitioners, regardless of the paradigm we work in, to use all our senses and experience to unlock the answers that lie within.
As a new practitioner I admit to clinging to props like iridology. As much as the philosophy of iris diagnosis is fascinating, it can be mere window dressing compared to taking a good case history. An experienced practitioner prompts the client to reveal the intricacies of every body system. Basic hands on information can be gathered, such as pulse, blood pressure and general observations. This comprises the magical 90% of diagnoses.
That’s not to say I never order tests or encourage a client to talk to their GP about having further investigations. Sometimes there is great urgency to do so. I just do it sparingly, when the obvious factors have been ruled out. This saves the client time, money and unnecessary pain. Talking mightn’t always be the sexy option. Sometimes changing a diet to eliminate symptoms can be inconvenient. But both are simple and effective, 90% of the time.
Despite the advances in technology, it still has its limitation. Take for example something as straight forward as a food allergy. Currently there’s a number of ways to test for them but sadly none of them are conclusive or always efficacious. The medically-favoured skin prick test tends to yield too many false positives and negatives for food (but is more reliable for contact allergens). The non-Medicare rebatable IgG test at least looks of the actual food allergy markers in the blood but is limited by the number of foods and the North American bias in the vegetables and seafood included in the test. Neither can diagnose the grey area of food intolerances. While an expensive breath test may predict lactose intolerance, it’s unable to exclude another common problem with dairy – an intolerance or allergy to the proteins found in milk products. Though clients are rarely told that may be their problem.
In the diverse world of complementary and alternative medicine it gets even hairier, ranging from esoteric techniques such as kinesiology and dowsing, to pseudo-scientific devises like Live Blood Analysis, Vega and Thera testing. The lack of scientific evidence for these practices aside, and without wishing to denigrate the integrity of the clinicians who rely on them, from closely observing how they are used I’ve found the results to be highly subjective, unreliable and disproportionally expensive.
In conventional medicine there’s growing discontent about the over-reliance on technology amongst some experienced doctors. A recent opinion piece in the New York Times explored some of these issues, yet it’s the responses to the piece that fleshes out some wider considerations including the profit made from medical imaging and excess tests being ordered in response to doctors fears of being sued.
As a culture we’ve fallen in love with scans. But we rarely hear about the downside of unnecessary trips through the scanner, other than sometimes ending up with a painful bill. Other than adverse reactions to contrast dyes and nuclear medicines, X-rays, CT Scans and MRI’s all expose the body to radiation, a known cause of some cancers. While a dental X-ray every couple of years is unlikely to significantly impact your risk; full body MRI scans, nuclear medicine and interventions all add up.
It’s one thing to order a test, yet another to skilfully interpret the results. An increasing reliance on technology, over experience and medical intuition, comes with its risks. I’ve witnessed misdiagnoses due to the limitations of what can be read on a scan and errors in human interpretation. These advances in science are there to compliment human diagnostic skills, not replace them.
One thing that is becoming a rarity in conventional medicine is time. Medical students are trained to take a history and examine a new patient in a few minutes. While this keeps immediate costs and waiting times down, it gives little space for someone to tell their story. This potentially leads to more misdiagnoses, incorrect prescribing and in the worst cases, deaths. Many doctors I’ve talked to over the years refer to time as a “luxury”. As GPs in Australia tend to see a minimum of 25-30 patients a day, the current health system and the restrictions of Medicare dictate that corners will inevitably be cut. Yet the system, despite its fast food-like approach to churning through clients, is still better than many others in the developed world.
Naturopathy, when executed with skill, is slow medicine. Just like “slow food”, extracting the essence of someone’s health story takes time. Making changes to a way of living, even longer. So excuse me if I offer no magic machine to come up with a diagnosis or automatically order expensive alternative pathology tests, but if you’ve got the time to tell me what is wrong, I’ll make the time to listen.
For both conventional and complementary practitioners, or those who like TV programs like “House”, take a look at Lisa Sander’s impressive and very readable book on diagnosis.
Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis