I’ve already tried rephrasing my point, so I’m not going to do it again. Suffice it to say that most of my patients are quite relieved when strep, or a heart attack, or cancer is ruled out, even if they never find an etiology for the physical symptoms. I’m not making this up.
Your “point” was that it is sometimes “more important” to discover that you do not have a particular illness/condition than to get a “certain diagnosis of what it is.”
More important. Those were your words.
Like you say to the patient “I don’t know what’s causing your chest pain, but you did not have a heart attack,” versus “your chest pain is caused by GERD.” See how it not being a heart attack is actually built right into the second one?
You aren’t rephrasing. You’re back-pedaling, which is okay, since you are wrong. Alas you are back-pedaling while insisting you are right, but presenting nothing to back it up. Of course people are relieved to find out cancer or a heart attack are “ruled out” (through magic, of course), but they still want to know what’s causing their symptoms. I highly doubt anyone is all that concerned about whether they have strep (usually treatable) or just feel exactly like they do, but don’t (no treatment indicated) and will continue to suffer indefinitely. Note how many people want antibiotics even though their illness is caused by a virus.
No, mostly what I hear is, “Thank goodness, I don’t need an antibiotic, the doctor says it’s not Strep.”
No, I’m not back pedalling. For many people hearing that it isn’t serious is all they wanted to know. Then they never go back to the doctor because they were told it wasn’t serious (which has it’s own problems; I’ve also seen people ignore heart attack symptoms because last time it wasn’t a heart attack.) Hearing what it isn’t is *more important to them *than getting an actual diagnosis.
WhyNot, I’ll back you up. About 7 years ago, I was getting a sharp pain in my chest. It wasn’t a really bad pain, but it was kind of annoying. When I told some people I work with about it (they asked why I was rubbing my chest), they told me, "You’re having chest pains, go to the emergency room. I demurred. I was young, I had to history of heart trouble, but the pain didn’t go away, and I started to get really worried about it.
So I went. An EKG and chest x-ray later, the doctor told me, “Well, its not your heart.” He concluded I’d probably pulled a muscle between my ribs, abut there was no way to tell for sure. I was incredibly relieved, was prescribed Naproxen and the pain went away a few days later. Still, I was glad I went.
It isn’t cancer is not the same as it isn’t serious.
Ditto for a heart attack.
Ditto for strep.
Et cetera.
And as you said, this can cause them to ignore symptoms which should not be ignored, making it even less “more important.” You have not demonstrated that it is more important than an actual diagnosis when you point out that they are glad to hear that it isn’t something in particular, merely that they may be satisfied with this consolation prize.
And doctors complain all the time about “having” to write prescriptions for colds just to make people shut up and go away. Are they all making it up?
What?
Of course ruling out life-threatening things is important. If it’s a life-threatening thing for which there is a course of treatment, you want to begin that treatment ASAP. Not something for which there is a treatment that must be started ASAP? well, OK, but glad we ruled it out.
Look at it this way: you are going on a long road trip, so you get your car checked, get all the tires aired up, including the spare, the brakes checked, the radiator pressure tested, fluids topped off, and soforth. Nothing is wrong with it. This means you can set out on your trip fairly confident that the car will not break down. Had something been wrong, you would have fixed it before the trip to avoid a breakdown on the highway far from home. Since nothing was wrong, you are no better off than before, in one sense, but in another, you have bought a sort of insurance, because something could have been wrong. It’s a little like opening the box and finding the cat alive and well.
You are certainly playing a game of statistics: out of so many sore throats, only n% will be strep. It would be nice if you could go to the doctor only for those n%, but you can’t. And because treating strep with an antibiotic is so important, you want to get 100% of your possible strep infections checked out.
My health would be the same. My comfort level in spending the weekend with my pregnant sister in law and her 83 year old grandmother would have been vastly different.
I never said ruling out life-threatening things was not important or that one should eschew such tests!
But if it’s MORE important to find out that you don’t have a particular thing than it is to find out what you DO have, as was claimed…
Then if a doctor said to a patient,after a full exam and some tests, “I can either tell you one thing you do NOT have, OR I can tell you what you DO have,” someone would reasonably take them up on the former at times, would they not?
Should you really be giving them colds?
I can’t believe I’m taking this bait. People would only take them up on the former if they were equally diagnosable. They aren’t.
At the moment you walk into the doctor’s office, the most important thing is to make sure you don’t have something that needs immediate care. After that, finding out what you do have can be done as necessary. And it might not even be necessary.
There is no bait here.
I didn’t say they were. I said that if you do not have a particular illness, finding out that you don’t have it is not more important than finding out what you do have. It is potentially important to do the test to exclude it, but if you don’t have it, you don’t have it. In reality, if you don’t have Disease X and you’ve never heard of it and neither has your doctor, so no test is done for it, you are better off (except of course for the fact that your doctor may not be as well-informed as you’d hope for the future).
But have it your way, it makes no difference. You’d have to have the test to find out how important the test turned out to be anyway, and I have not said otherwise.
What? Am I just tired here or is this some semantic nonsense?
The poster is missing the point that while it’s a bit of an oversimplification, there are basically two categories of illness: ones for which you must immediately start an illness specific treatment, or the outcome will be bad, and ones which are self-terminating, and you may, if you wish, choose among various palliative treatments.
(Yes, I know there are also the untreatable terminal diseases, and the watch-and-wait, maybe we’ll start a protocol later, and much more gray area, but I said I was oversimplifying.)
Illnesses share symptoms. An inner ear infection could be a brain tumor. Since an inner ear infection is rather easy to diagnose, and brain tumors unusual, the doctors will probably look for “inner ear infection” first, so that’s not really a good example. Strep throat is better. Bacterial infections don’t go away be themselves easily, and ruling out strep is easy. Differentiating a bacterial sinus infection from a viral infection is a little harder, and in a patient like me, with lots of antibiotic allergies, and no tonsils (appearance of tonsils can help distinguish bacterial from viral).
So, when I have an obvious infection and a bad sore throat, I go in for a culture. If it’s positive, I get antibiotics. If it’s negative, but I have a high fever, and other bacterial indications, like a particular appearance of my eyes, and really opaque mucous, the doctor will probably gibe me antibiotics then, too. If there are fewer indications of a bacterial infection, but she will give me the “bad cold” protocol, and tell me to call if there’s no change in three days, at which point, she may decide to phone in antibiotics (I have a history of non-strep bacterial sinus infections). If I’m getting better, she calls it a cold.
It’s never happened to me, but I assume if I developed GI symptoms, she might suspect the flu, even if I had been vaccinated. It would probably be too late for antivirals, but she might have other advice, and at least would probably be willing to give me a work note to stay home.
It’s important to know strep ASAP; other bacterial infections are probably not going away without antibiotics, but getting on the is not a STAT situation, and it’s not important to know which bacterium. If it’s viral, it’s not important to know which virus, except that it is important to watch a patient a little more closely if the person did not have a flu shot.
Then, of course, there is always the allergy, that can share symptoms with upper respiratory infections. GPs don’t ferret out the exact cause of your allergy, but if your symptoms persist for a long time without getting better or worse, and without fever, the doctor will probably suggest Claritin. If that fixes you, there’s no real need to know if the problem is the cat in the apartment about you, or pollen season. If you want to know, the doctor can refer you to an allergist.
No, you simply did not understand what I have said.
You saying I am “missing the point” that there are two kinds of illnesses except also some other kinds does make me wonder exactly what you think I’ve said, but between the self-admitted poor examples and other meanderings here, I am not able to tease out what you think I believe. It makes no difference, as I said. I am not suggesting a different course of action per case on the part of the patient or the medical practitioner, since no one knows the test results in advance.
It sounds like you are saying you should only go to the doctor when you have something that is both serious and treatable, without acknowledging that there is no way to know that without first going to the doctor.
Ideally not, but it was Christmas and skipping out on that is kind of a big deal. And if my efforts to keep my germs to myself should fail…well, nobody ever wound up in the ICU or the funeral home from the common cold. Influenza’s a whole other ballgame in terms of potentially serious sequellae, and pregnant ladies and the elderly are among the populations most likely to suffer serious issue from influenza infection. If the flu test was positive I would have stayed home, Christmas or no Christmas, rather than take the risk. But it was negative, and my quality of life was quite a lot higher spending Christmas with my family but not hugging the high-risk members and Lysoling everything I touched than it would have been sitting at home bored and depressed.
Quality of life is kind of a big deal in healthcare, especially when it’s the only thing you can actually do anything about.
No, I’m not saying that at all. In fact, I pointed out that one must take the test to know its result at least twice now.
I was responding to this statement by WhyNot:
“Learning what it isn’t by ruling out life threatening things is sometimes more important than getting a certain diagnosis of what it is.”
This statement does not say “ruling out life threatening things is good” or “ruling out life threatening things is necessary” or “ruling out life threatening things is important”; it says it is “sometimes more important than getting a certain diagnosis.”
More important.
I think that it can be important, that it may be necessary, and that it may be of benefit, but…
I do not think it is more important that getting a certain diagnosis.
It could alleviate a very specific worry. But most such worriers will immediately jump to “but what IS it?” and worry about that instead. I suppose some have only a specific phobia or don’t even know about the other stuff they could fear, or express relief at the negative test, then start the rest of their worrying at home, so at least they got a short break.
I think that the statement I quoted above is exactly the type of reasoning that occurs when you accept the premise that “Doctor knows best” and back-figure from there upon hearing of virtually any action by a doctor.
Doctor often knows very little though, like anyone else, so I am certainly in favor of tests that will not be subject to a doctor’s fallibility.
It’s not strep, it’s not the flu, it’s not allergies; it’s a viral infection of the common cold types. There are thousands of these, and the treatment is the same for each: rest, fluids, Tylenol for fever and body aches, decongestants and cough medicine as needed. Anti-virals won’t help at this point in the infection, and at any rate are overkill, because these infections are not serious. There is not point in trying to narrow down exactly which one you have, because the treatment plan will not change.
Call back in three days if you have not improved at all, or gotten worse, because it is possible you had a false negative strep test or flu test, or that remotely possible you have something really unusual that most doctors would not consider unless you had recently returned from abroad, or are immuno-compromised by HIV or post-transplant drugs, which you are not, or have somehow lost a titer to a vaccine-controlled illness. Those things are so unlikely, that it is not worth spending the money on tests without giving the “common cold” theory a test by waiting a few days.
How does any of this apply to what I said?
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Let’s look at strep
Scenario 1A: you have strep, but do not yet know it. You go to the doctor. A test for strep is ordered, it comes back positive, you are prescribed antibiotics, you take them, you improve a bit sooner than you would have without them with a bit less risk of complications, etc. In this scenario though, there is no “life threatening thing ruled out,” or even non-life-threatening, as your test was positive. Therefore we may discard this scenario entirely as irrelevant.
Scenario 1B: you do not have strep, but you do not yet know this. You go to the doctor. A test for strep is ordered and it comes back negative. You are prescribed nothing, your symptoms remain, and you’ve trekked to the doctor, emptied your wallet, possibly picked up some additional illness while there in your weakened state (maybe strep!), and benefitted only in one possible way: if you had some preposterously specific concern that you had strep and said concern has now been alleviated. It shouldn’t be, since the test fails to detect up to 20% of strep cases, but hopefully you don’t know that, and can rest easy with your strep-like symptoms, I guess. -
Or maybe flu…
Scenario 2A: you have flu, but do not yet know it. You go to the doctor and get tested, because what the heck, insurance will pay. The test is correct, in spite of being notoriously unreliable. The doctor dutifully prescribes you Tamiflu, though you’ve already missed the two day window during which it could make a difference, but whatever, hopefully you don’t know that. Regardless, we can throw this scenario out as well, as you do have flu, so nothing has been ruled out by a test, so it is not relevant.
Scenario 2B: you do not have flu, but for some reason you feel compelled to get tested. The test says you don’t have flu. You go home, continuing to feel like you might have the flu, but now your worries that you might have the flu are over? Hopefully you don’t have internet access and won’t find out that the rapid test is not terribly accurate. Of course you could do the test that takes days, but by then the anti-virals wouldn’t help anyway. You remain flu-ey, poorer, and no better off. -
Allergies? No one is going to test you for allergies because you have a few days of cold-like symptoms, so, irrelevant.
Can you point me at the part where the negative test turned out to be the important thing?
And not to split hairs, but you are confusing palliative care with treatment.
Did you go to a orthopedic doctor or a regular family doctor? And did you have any xrays or other tests?