I taught a weekend course in Flagstaff this weekend. The students were engaged and thoughtful. We had a patient case study to go over the principles of diagnosis and treatment.
The set up was a perfect reflection of daily practice: confusing and unexpected.
After going through the exam, the discussion, and the diagnosis, one of the students asked me about how confident I felt about the diagnosis and plan. I said something off the cuff about 90% that she would have a major breakthrough in pain and confidence.
I could tell she was very worried about that.
Here is the disconnect: she thought that it mattered that I was absolutely correct.
What I meant is that the presentation, the diagnosis and treatment were things I had previously seen before. Based on that experience and my clinical expertise, there was a 10% chance in my mind that I would be off on the prognosis and plan.
The diagnosis is never written in stone with complex presentations. As a clinician, I always have to be open to being wrong. That is why our clinic requires a change in plan of care if we do not see 80% improvement in 3 visits. When giving a diagnosis, the purpose is to draw a line in the sand to allow for prediction of improvement. It is should invite critical thinking and constant rechecking.
It is dynamic and changing.
Diagnosis in musculoskeletal medicine must be constantly scrutinized and I put as many barriers in place to stop confirmation bias. If someone is not improving, that is a big sign that either the diagnosis or treatment plan are not right.
Medicine is not certain and we need to be OK with that while being as transparent as possible with the patient about this uncertainty. That means constant re evaluation and inviting the patient to be as honest as possible about what they are feeling.