Insights into navigating American healthcare — Getting to the root

If I meet a patient who had one or two previous psychiatrists, I immediately gain hindsight plus the insight the patient acquired during those prior encounters. This is an incredible informational advantage.

I am like a machine that turns information into effective treatment. I do my best to elicit the relevant information. My greatest eliciting tool is quiet patience applied over time. Unfortunately, few patients intuitively sense what information is most relevant to doctors. This is not a knock against patients — doctors receive enough training to develop the requisite skills to confidently elicit the relevant information — but it takes no stretch of the imagination to intuit that patients who feed the right inputs get the best outputs. Doctors are made out of emotional meat, just like everyone else.

As a psychiatrist, in order for me to get the best quality information I must build rapport, maintain trust, and instinctually get some things correct early on lest I lose the patient to the follow up void. Simultaneously, I must use empathy in my voice or else my best attempts at communication will be ignored or ridiculed.

To make matters more complex, a person is not an illness. A person has biases, shame, time limitations, financial limitations, and preferences. Likewise, the healthcare system is fractured, disconnected, and at times impossible to navigate. The healthcare system offers a bevy of mixed incentives to both clinicians and patients.

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Young student doctor me learned the saying, “medicine is a science, healing is an art…” Real world me knows the last part “…and healthcare is a business.” It is an unavoidable reality that American healthcare operates in a capitalist market surrounded by strict regulation and high cost.

It may require years to get to a useful diagnosis for all of the above reasons. The best diagnosis is one that has a straightforward treatment plan. I am a specialist, so I do not expect many patients who have straightforward treatment plans to make it to my door. So how to best navigate the complexity? I hope to illuminate the thought processes the most effective clinicians use. This may aid in identifying the doctor you want to work with.

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Doctors may use heuristics to “save time,” but they first learned a systematic approach to diagnosis and treatment.

Symptoms tell us problems, and problems need to be differentiated. Each symptom is quantified in its timing, onset, duration, location, frequency, intensity, quality, radiations, etc. Pertinent negatives help exclude large swaths of fruitless pathways.

Many times the causes of an illness are multifactorial — in medical school there is a common mnemonic for differentiating a diagnosis: VINDICATE. To learn proper diagnostics I was trained to give each problem its own differential.

For example, imagine a patient with symptoms of acute abdominal pain radiating through the back and visual hallucinations. The patient also has signs of fever, tremor, and confusion. After investigation via history, imaging, and labs, the problem list shapes up to be: pancreatitis and delirium. Now run those problems through the mnemonic — this can help us gain insight into more accurate diagnostics. I completed a few as examples for effect:

Vascular

Inflammatory/infectious — (encephalitis)

Neoplastic — (brain metastasis)

Degenerative

Idiopathic/iatrogenic/intoxication — (alcohol withdrawal)

Congenital

Autoimmune

Traumatic

Endocrine

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Practicing this helps us to think in differentials, and now mental effort must move towards ruling OUT the diagnoses that do not fit well. What ever is left needs be worked up to become ruled IN. Adopting the rule of parsimony (Occam’s razor) guides workups. If one diagnosis ties all the problems together, that is a more probable explanation than multiple diagnoses occurring simultaneously. (Unfortunately the most ill people have problem lists longer than a Walgreens receipt).

In the example above I imagined acute pancreatitis secondary to chronic alcohol use, with onset of delirium tremens (DTs) due to alcohol withdrawal. The primary illness is alcohol use disorder, the likely cause of pancreatitis (which has a fun differential if you wish to look it up). Pancreatitis then instigated the patient to stop drinking and thus develop delirium tremens.

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Some patients will remain curious, what is the “root cause?” If we can remove the infected roots then we have a cure!

The differential diagnosis does not get us all the way to the root cause of disease. If in physics we observe matter, and note that atoms are the building blocks of matter, we still might wonder what are atoms made of?

Root causes, the proverbial subatomic particles, are biology, psychology, and sociology. i.e. genes, nurture, and environment.

And here’s the rub, dear reader, gene therapy, lifestyle modifications, and sociologic changes are out of reach for most people. We do not get to choose where, when, and who we are born to. We do not get to choose what society favors, what illusions of choice we are presented with, and what our genes dictate we act like.

Why did that patient in my made up example get pancreatitis? Chronic alcohol consumption. Why did the patient consume alcohol chronically? Genes coding a favorable response to alcohol, psychologic response to ethanol in the brain, and exposure/access to the drug. It is simple to describe, but not so helpful at identifying how to help next.

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So let us go back up a step to the diagnosis level. The diagnosis is not often the root cause, however a discrete diagnosis can be rigorously and scientifically tested against a treatment plan and the pathway of relief becomes revealed. We give the patient morphine and IV fluids to treat the acute pancreatitis. We protect the patient from DTs with specialized sedation, if available, and antipsychotics with benzodiazepines if sedation is unavailable. We search for common comorbidities once the patient is stable, such as hepatitis, gall stones, esophageal rupture, depression, and PTSD. We counsel alcohol cessation and use effective medication to reduce risk of relapse (spontaneous lifestyle modification is out of reach for most, even those who experience the extreme pain of pancreatitis). This takes a tremendous team of people and is both time consuming and extremely expensive to coordinate.

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I hope this note effectively colors in a small slice of the modern American healthcare system — the differential diagnosis. A doctor who thinks in differentials and uses the rule of parsimony can effectively diagnose the rare stuff. A focused interview requires a reasonable amount of time, so I will discuss navigating time in another note.

-Doc