In medical school we are taught to begin a consultation with an open-ended question such as,  “How can I help you?” The top ten diseases clinicians record following  an initial encounter  include: upper respiratory tract infections, hypertension, arthritis, diabetes, depression, pneumonia, acute middle ear infection, back pain and dermatitis. That’s in developed countries.  It’s a little different in developing countries where depression and back pain do not make the cut, either because there is little overall data collection, or these particular conditions are not recorded. 

 

Top presenting symptoms have high levels of low value testing

Compare that list with patients’ top ten reasons for visit, most of which are symptom, not disease, driven: cough, back pain, abdominal pain, sore throat, skin rash, fever, headache, leg pain, anxiety and tiredness.

So why is there a difference? In the money-driven health economy of the US, clinicians are required to focus on labelling disease. Reimbursement pathways rely heavily on a diagnosis, usually using a disease classification code such as ICD or SnoMed, and then following up with complex and often expensive management strategies.

Symptoms are rare in classification systems and when they are present they are poorly delineated. For example, the ICD-10 code for pain (R52) is listed as unspecified and contained in a chapter dedicated to symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified.

Patients, conversely, are usually interested in a disease diagnosis only if it assists the validation of their presenting problem and /or provides a route to treatment and hopefully alleviation of symptoms. Quite often the pathway to diagnosis proceeds in steps, starting from the most accessible, least costly activities such as X-rays. Unfortunately, low cost too often yields low value results.  In one very large study, low-value diagnostic testing, that is testing not likely to yield an advance on diagnosis or management, was common, affecting up to 1 in 5 patients. 

Unsurprisingly, the symptoms that lead to the highest levels of low value testing mirror some of the top presenting symptoms of patients such as low back pain, headache and upper respiratory symptoms. 

Dealing with competing views between patients and clinicians is not new. What we are discovering, though, is that both paradigms – symptom and disease – are useful.. 

Nonetheless, it’s hard and perhaps dismissive for high-achieving clinicians to give up on the quest for a diagnosis, especially when some non-specific symptoms can lead to a diagnosis that has high potential for resolution by rapid and active treatment. For example, tiredness is a non-specific symptom, which when related to anemia, thyroid disease or depression, has high potential for resolution by rapid and active treatment. However, tiredness as an ongoing symptom, unrelated to a particular disease, is often beyond the realm of conventional medicine, irrespective of the number of low-value diagnostic tests. 

But when help is beyond diagnosis and treatment, it is time to say: we can’t help you.