Sometimes the best medical test is the test of time | Expert Opinion

The middle-aged patient who came to the office with stomach issues looked more worried than ill. She had experienced bloating and irregular bowel movements for two days, following a family gathering. No others in attendance had similar symptoms.

I felt reassured that she was not running a fever or bleeding, and her physical examination was normal except for slightly elevated blood pressure. She told me that she feared the symptoms pointed to a problem with her pancreas, a concern supported by conversations with a friend and her own research on ChatGPT.

“Which tests should I have? Would blood work and abdominal imaging like a CT scan or ultrasound be best?” she asked.

I acknowledged her worries, but explained that her symptoms and examination were most consistent with stomach flu, formally diagnosed as viral gastroenteritis. We discussed how this differs from pancreas inflammation and other serious ailments that usually cause more severe pain, vomiting, and abdominal tenderness. I validated her research as sensible; it just needed to be considered in the context of her own story and physical exam findings.

We reviewed the list of tests that she wanted to consider, and together landed on the most useful one in this situation – the test of time. With gastroenteritis, I expected her symptoms to gradually improve over the next two days with a bland diet, extra fluids, and rest. If she was not better by then, or if her symptoms worsened, I would re-evaluate her and order further diagnostic testing.

Two days later, when one of our nurses called to check on her, she was feeling much better.

Why did I want to hold off on just doing the tests to be sure nothing else is wrong? Jumping too quickly to blood tests and imaging to “rule out” unlikely diagnoses may cause more confusion. There may be false positives, false negatives, or results right on the border between normal and abnormal. Instead of supporting or excluding a diagnosis, the test results can obscure it.

Time can be an excellent diagnostic test, since many illnesses have a predictable course. However, clinicians should always look out for exceptions. A notable example is chest pain. Midchest tightness, accompanied by sweating and shortness of breath, are classic symptoms of a heart attack. Here, taking extra time is too risky, since missing a heart attack diagnosis can be catastrophic. Most clinicians have a very low threshold to move right to specific diagnostic testing and emergency care when there is any uncertainty about the cause of chest symptoms in middle-aged or older adults.

The diagnostic test of time is powerful but comes with an important caveat: it requires a trusting clinician-patient partnership. My patient and I have known each other for years. I trust that she will reach out if her condition worsens, and she trusts that I will listen, apply clinical judgment in her best interest, and be reachable for follow up. I consider this relationship the special chemistry of primary care.

When your doctor recommends “give it time,” this can be a sensible diagnostic strategy. Yet don’t take it at face value. Make sure you understand the rationale, and that all of your concerns are addressed. Most importantly, ask what to look out for and have a reliable way to contact the office if your condition changes or worsens. If you are in severe distress, go to the emergency room. Trust your doctor, along with your own instincts.

Jeffrey Millstein is an internist and regional medical director for Penn Primary and Specialty Care.