Good Workups

Everyday I met new people and hear their stories, both what’s going on in their life and their medical history. Every once in a while, I am astounded at what I hear. They tell me stories of how doctors have managed their cases, and I am appalled – what is medicine coming to?

In medical school you are taught about the “standards of care.” These are guidelines about how to treat conditions like PCOS, migraines, hypertension or diabetes, to name a few examples. Knowing the standards of care for each condition is important, because if you deviate from them, you need to let your patient know, but also, if a doctor hasn’t followed the standards of care, especially when working up a patient to investiage if they have xyz condition, it raises some red flags because they need to be worked up accordingly – it’s a doctors due dilligence.

As a Naturopathic doctor, I don’t have a Naturopathic standard of care to follow – we learn the same standards of care that DOs and MDs use. I am happy about this (while some of my colleagues believe we should establish and teach just ND standard of care), because knowing what’s going on in conventional medicine is very important to manage some emergencies and also to work up a patient accordingly before using my alternative therapies to treat them.

When it gets interesting, however, is when a patient comes into my office and they claim they have seen 5, 10 or more doctors, that they have xyz symptoms, and that they had xyz testing. While the patient believes they have been appropriately worked up for a typical list of differential diagnoses (list of possible diagnoses based on the patient’s symptom picture), I usually find they have not.

Generally what happens is, when a patient walks into the office, a doctor will then create a DDX based on what the patient tells them, then the doctor investigates using the standards of care and any other diagnostic tricks they’ve learned throughout their practice, the results of these tests then narrow down the DDX and eventually get the practioner to one or two possible diagnoses. Then it’s time to refine, and begin treatment.

Typically when patients visit me, they have been worked up. I ask them questions to make sure I understand what their previous practioners have done (one rule in medicine is that you always do your own investigating, even though a patient claims they’ve had a thorough workup), and then if they have had an appropriate workup, we move on to what I do best – the natural therapies and figuring out the root cause. But too often, and especially recently, I discover that the patient hasn’t been appropriately worked up, and I am either left to work them up, diagnose the condition and figure out what’s truly going on behind their medical diagnosis (putting my detective hat on!), or I need to recommend that they see xyz type of practioner to the standard workup for me.

This is unacceptable. While doctors do not know everything, why is there this pretense that we have to “know” it all? We are human. We do our best with what we’ve been given. Sometimes that makes our job difficult, especially when patients are poor historians. But to not do all the appropriate investigations while using the standards of care, baffles me. If that condition is on your DDX, then you need to investigate!

Patients, ask questions of your doctors. If they brush you off or aren’t able to fully explain something to you, find another doctor. Your health is important and their unwillingness to explain their thoughts about your case, is a big red flag.

Doctors, ask questions of your patients. Don’t assume they’ve had the appropriate workup. Make a long DDX and have reasons why you cross conditions off the list. Think about the medical dangers, the zebras and the horses. Include them all. If you can’t work them up (some states limit what us NDs can do, because each state has it’s own set of rules and scope of practice), send them to someone who can. If the need for workup is urgent, make sure you explain this to the patient and get them to a specialist in an appropriate amount of time.

I went into medicine because I hate the mediocrity that I sometimes see in the profession.

Be the medicine, and stay curious!

— Dr. Meg

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