The Agatha Christie “whodunit” approach to diagnosis doesn’t work when diagnosing why you hurt; here’s why.
Everyone who watched the series House on Television has seen the mythic Dr. House diagnose all these difficult-to-diagnose cases when other doctors were unable to figure out the case. Of course, this led to the proper treatment and a miracle cure for the patient.
In the musculoskeletal realm, patients often have echoed this with terms like sciatica when they have leg pain or a pinched nerve that they were told they had by another healthcare practitioner. Sometimes patients are told they may have a disease and are sent around to different practitioners such as a rheumatologist to rule out a disease condition that can be life-altering. Others have a long-term problem they attribute to a disc that was diagnosed via MRI years prior, even though the symptoms do not align with the MRI diagnosis.
Often, these diagnoses are wrong and lead to poor case management, unnecessary stress for the patient, unnecessary tests, unhelpful procedures, and unnecessary costs to the patient and the system.
One patient in her 20s had a biopsy of a muscle to determine a disease that was ruled out. She could have been referred to someone who would have been more qualified to understand why she hurt without the test, the incision to do the test, or the risks involved when the problems were visible to the naked eye.
When doctors don’t know, they test. All doctors including chiropractors do this. When you know more, you are less likely to test. Perhaps this is why most chiropractors order fewer MRI scans than most medical physicians. The old idea of I want to know often is attached to an unnecessary MRI which is more likely to show you a history of malfunction and what happens because of it instead of your actual problem in most cases.
The simple approach of taking a great detailed history of the problem, doing a holistic thorough evaluation of the patient, and a trial of chiropractic care is all that is ever needed to resolve the pain and the problem(s). There is an art to keeping things simple, but our current system is set up for caring for illnesses, many of which are merely categories that people fit into.
As we are all different, and we all adapt constantly, many painful problems are functional and mechanical in nature, and to understand the pain and how to relieve it, the healthcare provider must understand you. They also must tailor the care to fit your unique problem and monitor the progress from visit to visit.
The old model of finding the problem does not fit when the shoulder pain you have with the impingement you developed is an expression of lower back and foot dysfunction going on for many years. The model also does not work when we view all lower back pain as the same whether you are tall, short, female, male, perform physical work, look at a computer all day, etc.
The idea of whodunit in diagnosis is often because we as providers did not take a primary care approach to understanding why you hurt or why you are having a problem or problems. It is not unusual for multiple complaints in the lower and upper body to be due to years of poor adaptation with a disc problem as the result of years of managing symptoms, rather than understanding the underlying problem.
In the world of chiropractic, many problems begin from the ground up and do not include the major trauma of a fall or a bad accident. The problem develops from years of poor function due to how we walk, the myofascial system, how we have learned to walk and move, etc.
Understand this first, treat to see if there is improvement (in most cases there is), and then offer exercise instruction, foot orthotics, and other sensible advice to help the patient feel better. In other words, keep it simple. Refer when it is not so simple.
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