The perils of diagnosis by investigation

The recent research released in June 2019 by Ferrell et al shows that there is no significant difference between the MRI findings of people with neck pain / whiplash, and those without pain. For many, this will be seen as groundbreaking research, but for those who specialize in the field of injury management from workplace or motor vehicle accidents, this is nothing new. 

What it should highlight though, is that there is a big issue arising in medicine, and that is the loss of clinical decision making and an over-reliance on investigations that ultimately results in the treatment focusing on management of the test result instead of managing the patient that is in front of them.

Diagnoses come from taking a history, performing an examination, and then determining what the diagnosis is from that. IF, the diagnosis is unclear or could be more than one thing, then further tests are performed to support or refute the differential diagnosis.

If tests are to be performed, then it’s important to tell the patient what you are specifically looking for, and what you expect to see that is normal for a person of the patient’s age, gender and other social factors.

If you are sending a patient for further investigation just because they are not getting better, BEFORE you do this, try starting again. Take a more thorough history. Perform a more thorough examination. Think laterally,and then if imaging is still required, get the right one done the first time.And know what is normal for a person of your patient’s demographic.

Unfortunately, doctor’s own biases can lead to them seeing something (anything) in the imaging and saying, “Well that MUST be what is causing the problem”.

But, so what, you say? Well, when the focus moves to treating something that is seen on imaging, it can result in the individual receiving the wrong diagnosis, and therefore sub-optimal treatment, with the patient not getting better. This then leads to more intervention and more frustration for the patient, not to mention extended suffering. 

And considering that the primary tenet of medicine is “Primum non nocere”, as health professionals we should all focus on spending time with our patients to discover what is wrong and provide a deeper level of care.