To search or not to search (for a diagnosis) | Expert Opinion

It’s easy to assume that every doctor’s visit follows the same script: A patient tells the doctor how they feel, the doctor does an exam, then orders labs and reviews data. At the end of the visit, or soon after, the doctor gives the patient a diagnosis, a treatment plan, and their problem is solved. On TV this is often a dramatic reveal; the diagnosis is like a golden ticket, only once this is in hand can treatment begin.

Rarely in the real world do these events proceed in such a linear fashion.

For some conditions, treatment relies heavily on an exact diagnosis. Cancer, for example, is defined by anatomic origin, genetic data (if available), degree of spread, and many other factors. These details inform the diagnosis, which will then shape the kind of treatment offered as well as the prognosis.

For other issues, we don’t even try to pin down an exact diagnosis. Take the common cold, or upper respiratory infection (URI). We know there are dozens of viruses (and even some bacteria) that can cause URI symptoms such as a runny nose, cough, sore throat, and low-grade fever. We don’t typically test for any of them (COVID being an important exception). Why not? Because knowing which bug is to blame won’t change treatment in the slightest. Instead, our time and efforts focus on those bothersome symptoms and how best to alleviate them.

When to refocus from diagnosis to treatment can be a difficult decision. Patients may perceive that not pursuing a detailed diagnosis means that their doctor isn’t concerned or that something is being missed. For a patient with low back pain, for example, assuming there aren’t any signs that their spinal cord is involved, I may discuss pain management and physical therapy without ordering radiology studies or referral to a surgeon. The diagnosis of “musculoskeletal low back pain” may sound vague, it doesn’t describe exactly where the pain originates or the exact cause. However, there is plenty of scientific evidence that first-line treatment like physical therapy can proceed without additional testing. We have additional evidence to show that anti-inflammatory medication and physical therapy alone will make a huge difference and are likely to be the only treatment needed.

While sending a patient for expensive radiology testing to collect more information is an option; this search for a more specific diagnosis will take time, extend the length of disability, and will not change the initial treatment. So our time is best spent managing symptoms and improving function.

This is often a surprise to patients. Some feel having a detailed and specific diagnosis is validating, it may help them educate themselves about their condition or join a support community.

I can understand that perspective and never want to discount it. What I try to communicate to my patients, however, is that even without a detailed diagnosis, it is important to explore how their symptoms affect how they function and feel, both physically and emotionally.

In fact, sometimes putting aside the search for a diagnosis allows more time for having these important conversations and helps both physician and patient to gain insight into treatment goals.

I like to think of the diagnosis as one step in the evaluation and treatment process, not necessarily the first (or only). My patient and I may want to spend more time initially discussing their quality of life or what steps they’ve already taken to try and manage their concern so I know how best to proceed. Pausing on a search for a detailed diagnosis isn’t giving up. Taking the time to explore the physical and emotional impact of symptoms, instead of being narrowly focused on diagnosis alone, will likely be more helpful to both patients and physicians in the long run.

Amanda Finegold Swain is a family medicine physician in the University of Pennsylvania Health System.