Family Medicine: The Differential Diagnosis

What could be causing this?

This is a question that Family Physicians often ask as they interact with patients.  The list of possibilities that is actually considered is called the "differential diagnosis".

The list can be huge, but the active considerations are limited by the brains of the patient and physician and time, sometimes supplemented by decision aids in print or online.  Processing the possibilities via the history, physical and differential diagnosis is part of the fun of Family Medicine.

Added to this intellectual component is the human centered, relationship based engagement of patient and physician in a unique decision making dyad.  The roles assumed by the members of the dyad alter the process of engagement and decision making, affecting the differential diagnosis and the subsequent diagnostic, therapeutic and patient education decisions.  The personal values of the dyad enter into the discussion frequently as do other contextual phenomena, such as life, family , education and work considerations.  One contextual element frequently encountered is the migration narrative or movement of the patient.  Where are they going?  What is next in their life, work or play?

How does their migration impact the differential diagnosis and the plan and follow-up?

What does the patient believe about their condition and the plan to address it?  Sometimes I'm surprised by the patient's activity on the agreed to plan.  Someone with a serious heart condition may stop a medication that keeps them out of emergency rooms and end up in an emergency room.  At the follow-up to the emergency visit, I want to determine where their heart is in its degeneration and consider dosage adjustment of medication or addition of other medications until it comes up that they stopped the medication.  "I thought that might be the cause of my indigestion" "I wasn't sleeping well and I thought the medicine might be part of my insomnia."

As we share better with each other, especially as we share the development of the differential diagnosis, it becomes easier to seek clarification about how and when to use the medication.  And when to share information with their Family Physician.

The Differential Diagnosis is one of the anchors of medical care.  It keeps us focused and engaged.

More later.

George Jones, Tim Tebow, Marcus Welby MD and Healthcare

George died, Tim was fired and Marcus was a re-run.

I always liked the music of Tammy Wynette more than George Jones.  I used to sing her songs when I was in Vietnam.  "Our D-I-V-O-R-C-E Becomes Final Today" was as fun to sing as "Stand by Your Man." I learned about George by listening to Tammy's songs.  I thought he might have some anger management issues.  Unless it was all about the alcoholism.  If he or Tammy had seen their Family Physician for help, the outcome of the marriage might have been better (but record, CD, DVD, downloads, and other sales might have suffered greatly). 

Tim, I like the way you play football, but traditionalist coaches in the NFL don't connect well with your unique value.  Wait a minute, that makes me think of my medical specialty- Family Medicine.  We're the most important health care professional in the fight to "bend the cost curve" of healthcare that's bankrupting America- BUT- we're unique and not understood, therefor have to be TRANSFORMED to REALLY be good.  In the process, we're being destroyed, dumbed-down, and looking for the exit or the independent practice using a Direct Primary Care business model across the street from the BEAST of healthcare.

Marcus, Marcus Wherefore art Thou, Marcus?  Where's Dr Kiley and Nurse Consuelo to help us when we're overloaded?

OK, maybe looking backward could be discouraging.  Onward EHR, Meaningless Use, Payment Centered Medical Homes, Phony Quality Initiatives, Evidenced-Based Shareholder Value and other key components of the future of healthcare.

George, I hear you singing "Who's Gonna Fill Their Shoes?"

What do you think?

Family Medicine Activist: #HAWMC Twitter Review Day 30 of 30

#HAWMC Day 30 Part 2     The Dr Synonymous Show

Here's what you can hear on Dr Synonymous Show for April 30, 2013:

The last day of the Health Activist Writers Month Challenge, health activists celebrated with their final post.  I went to Twitter and commented on several of them (including mine-shamelessly).  Go Activists! 

3. Sharon Rainey ‏@sharonrainey 2h

   Day 30 - #HAWMC @wegohealth Write a recap of my experience. What have I learned? #lyme http://www.myneighborsnetwork.com/index.cfm?neighborhood&neighboraction=livingWithLyme&content_id=281 …

   
     Amanda ‏@LAlupusLady 3h
4. “Believe in yourself and you can achieve greatness in your life.” @JudyBlume ~ #HAWMC #Lupus http://ow.ly/kAe0E  #LupusStyle

   
   

   Followed by Wing Of Zock and 5 others

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5. Audrey Birt ‏@AudreyBirt 5h

   Audrey Birt's blog: Day 30 reflections on this "one wild and precious ... http://audreybirt.blogspot.com/2013/04/day-30-reflections-on-this-one-wild-and.html?spref=tw … #hawmc on challenges and insights

   
   

   Followed by Alicia C. Staley

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6. chronicIllnessprobs ‏@chronicallycool 6h

   Day 30: Recap #HAWMC: Day 30 (April 30) – Recap  You made it! 30 posts in 30 days! Today, write a recap of yo... http://bit.ly/12R5jmi 

   
   

   Followed by WEGO Health

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   Day 30: Recap #HAWMC

   Day 30 (April 30) – Recap  You made it! 30 posts in 30 days! Today, write a recap of your experience. What was your favorite prompt? Least favorite? What have you learned?  Describe your HAWMC ex...

   WordPress.com @wordpressdotcom · Follow
7. RAW ‏@RAW4RA 8h

   I'm saving today's #HAWMC prompt until I am done. The next 11 days I'll be catching up w/posts. U can read them here: http://ALifeReinvented.trwonline.net 

   
   

   Followed by Kelly Young and 4 others

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8. Emily ‏@emilymword 10h

   Day 30: Congrats to everyone who finished the Health Activist Writers' Month Challenge! http://thatmword.com/post/49265415320/day-30-recap … #HAWMC #migraine

   
   

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9. A. Patrick Jonas, MD ‏@apjonas 21h

   Dr Synonymous: Family Medicine Activist: "Spendipulous" #HAWMC Day 30! WEGO HAWM Challenge Ends!... http://drsynonymous.blogspot.com/2013/04/family-medicine-activist-spendipulous.html?spref=tw … #FMRevolution

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10. A. Patrick Jonas, MD ‏@apjonas 21h

    Dr Synonymous: Family Medicine Activist: Self Love- Easier Spoken Than Written... http://drsynonymous.blogspot.com/2013/04/family-medicine-activist-self-love.html?spref=tw … #HAWMC Day 29 #FMRevolution

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11. 710.9 ‏@710dot9 29 Apr

    #HAWMC Day29 - Yeah, I'm pretty awesome. - Here are three examples: I am a great, super-supportive friend.... http://tmblr.co/Z1L2wsjo8BRN 

    and.html?spref=tw … #HAWMC Day 28 #hcsm

    Go to Twitter.com to read these posts, or click on them here and they will probably work on this post.

    I enjoyed reading these posts.  I hope that you do, too.

    Peace to all.

      

Family Medicine Activist: "Spendipulous" Health Activist Writers Month Challenge Ends

#HAWMC Day 30!

Today’s HAWMC  prompt was “’Describe your HAWMC experience in one word!”


                     "Spendipulous!"



Peace to All... Until the next Challenge.

Family Medicine Activist: Self Love- Easier Spoken Than Written

#HAWMC Day 29

I’m participating in WegoHealth’s Health Activist Writer’s Month Challenge. This post was written in response to their prompt, “We all know Health Activists are awesome. Share three things you love about yourself, things you’re great at, or just want to share. Don’t undercut or signpost!”

I will look in my mirror daily and say, " In spite of your previous mistakes, I love you."  I admit that if I just say to me in the mirror, "I Love You," I feel uncomfortable.  Using the disclaimer about my previous mistakes makes it doable.

Self love is difficult to write about since it seems to cross a lot of lines in our childhood humility training.  Many religious persons believe what the Bible says about self love:  "Love your neighbor as yourself."  Verses from the Old Testament and New Testament echo the same message.

Leviticus 19:18 (NKJV)
¹⁸  You shall not take vengeance, nor bear any grudge against the children of your people, but you shall love your neighbor as yourself: I am the LORD.

---

Leviticus 19:34 (NKJV)
³⁴  The stranger who dwells among you shall be to you as one born among you, and you shall love him as yourself; for you were strangers in the land of Egypt: I am the LORD your God.

---

Matthew 19:19 (NKJV)
¹⁹  'Honor your father and your mother,' and, 'You shall love your neighbor as yourself.' "

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Matthew 22:39 (NKJV)
³⁹  And the second is like it: 'You shall love your neighbor as yourself.'

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Mark 12:31 (NKJV)
³¹  And the second, like it, is this: 'You shall love your neighbor as yourself.' There is no other commandment greater than these."

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Luke 10:27 (NKJV)
²⁷  So he answered and said, "'You shall love the LORD your God with all your heart, with all your soul, with all your strength, and with all your mind,' and 'your neighbor as yourself.' "

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Romans 13:9 (NKJV)
⁹  For the commandments, "You shall not commit adultery," "You shall not murder," "You shall not steal," "You shall not bear false witness," "You shall not covet," and if there is any other commandment, are all summed up in this saying, namely, "You shall love your neighbor as yourself."

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Galatians 5:14 (NKJV)
¹⁴  For all the law is fulfilled in one word, even in this: "You shall love your neighbor as yourself."

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James 2:8 (NKJV)
⁸  If you really fulfill the royal law according to the Scripture, "You shall love your neighbor as yourself," you do well;

---

 So why  is it so hard to write about self love.  Wouldn't many religions consider it sinful not to follow the Biblical commandments?

"The meek shall inherit the earth," comes to mind as a subtle threat to those with too much self love.  Let's just go with the central message of, "You shall love your neighbor as yourself."  How does this manifest in Family Medicine practice?

I assume that my patients are my neighbors.  I should treat them as I would like to be treated by my Family Physician.  I should listen to them as I would like my physician to listen to me.  I should follow the process of the Human Centered Health Home (HCHH): by Respecting, Protecting, Connecting, Detecting, Correcting and Reflecting both the patient and myself.  (Search this blog site for several posts about the HCHH)

That does afford a better balance in the patient-physician dyad, in which we each may fulfill several roles during our encounters and across our relationship.  OK, I love myself and will manifest an equal importance to that I afford my patients.  It will take some reminding and practice.

Are you able to write about self love?  Does it feel uncomfortable?  Does your mirror or your mother know that you admire yourself?

Let's work on our self love together.

Family Medicine: Rare Disease Frustrations Persist

#HAWMC Day 27

    Day 28 #HAWMC @wegohealth  What have I learned about being a #Lyme patient that surprised me

the most?
Sharon Rainey

"What have I learned about being a patient that surprised me the most? 

I was flabbergasted as I went through the initial process of getting the lyme diagnosis and how many medical professionals chastised, degraded, ignored, and negated me as I asked questions to the get to the bottom of the issue.  

I was shocked by how many physicians threw prescriptions at me and even admitted that they would not look for the source of my pain.  Rather, they would only treat me symptomatically."

 Something failed in the engagements of Ms. Rainey with multiple physicians.  I'm glad she eventually found someone she could work with.  Rare and unusual diagnoses sometimes tax the decision making style of the individual physician and the system of work flow and various incentives.  Interacting with the person with the rare diagnosis may require several visits to systematically clarify what is happening.  The differential diagnosis starts with more common possibilities, working toward less likely diagnoses.

Since we already know that Lyme disease is a major diagnosis, we know it's difficult to arrive at that diagnosis.  We also know that the search strategy can get expensive to test and clarify the options in the differential diagnosis.

I once knew a physician from near Lyme, Connecticut who went into congestive heart failure when she was at a major university in North Carolina to give a medical presentatiuon (not UNC).  She knew a great deal about Lyme disease (surprise) and asked the attending cardiologist if he would order a Lyme test since she lived near Lyme, CT and all her signs and symptoms could be explained by Lyme disease as the diagnosis.  The cardiologist refused to order the test.

They got her heart rate controlled and flushed out lots of fluid with diuretics well enough to get her back home.  On arrival, she went to the county health department, was tested for Lyme disease, which tested positive, was treated and her heart reverted to its normal rhythm and function in a few weeks.  That physician knew some of the frustration that Ms. Rainey felt, but she was A PHYSICIAN BEING DISSED BY HER OWN COLLEAGUES.  Very pathetic, indeed.

Ms. Rainey wisely kept going until she found physicians who would partner better.  Congratulations, Ms. Rainey on your wisdom.

It's true, though, that on our bad days, all physicians or patients may not connect well.  Follow up visits may be needed to best clarify how the relationship may serve the dyad of patient and physician.  Terminating the relationship sometimes is necessary, as in the case of Ms. Rainey and my friend from  CT.