On a previous post on transparency in health care, a commenter (Carol) asks the following excellent question:

You might offer your thoughts regarding conventional medicine’s penchant to treat symptoms rather than heal the underlying problem. Is this a manifestation of the restrictive insurance company protocols? Is it the way medical schools train physicians to think? Is it born out of an historic medical continuum? Something else entirely?

This is a bit off the topic of quality in medicine–although on second thought, it does relate to quality–at least to the perception of quality.

Of course I cannot speak for all physicians, but primarily for myself, and for those physicians I know and work with. Does contemporary medicine emphasize the management of symptoms over the diagnosis and treatment of underlying causes? The question seems to presuppose that it does–and perhaps in Carol’s experience that has been the case. But I believe the presupposition is incorrect, at least for most physicians.

Physicians are by training and disposition problem-solvers: we are drawn to the solution of puzzles, the solving of mysteries, the resolution of quandaries and dilemmas. We thrive on this stuff. A few days spent accompanying interns and residents on teaching rounds clearly demonstrates this: students are presented with signs, symptoms, lab results, x-ray findings, and asked to make a diagnosis, or give a list of possible diagnoses, and suggest additional tests or studies to narrow these down. “Stump the resident” is a favorite game of every teaching physician. This is our training: we are always looking for the underlying cause of a symptom or problem.

Any physician who simply treats symptoms without trying to determine root causes and the correct diagnosis is at best incurious, or more likely, poorly trained or inept. You would fire a mechanic who tried to fixed your car without understanding the problem first; you should fire a physician who does the same.

But before you pick up the phone to fire your doctor, you might want to think this issue through a bit more thoroughly.

Symptoms are but one of the many tools used by physicians to get to the bottom of a patient’s problem. They are, of course, paramount to the patient: in most cases, this is why you went to the doctor in the first place. And usually, patients have some idea or opinion about what is causing their symptoms. But symptoms can be wildly misleading, and patients — even well-informed ones — are more often wrong than right in their self-diagnosis.

Many serious diseases may have little or no symptoms at all, or present mild symptoms easily dismissed as non-serious problems. The body is also rather adept at presenting with symptoms in areas remote from the problem. A kidney stone may present with pain in the groin, nausea, frequent urination — or no symptoms at all. Leg pain may be from a back problem, or a blood vessel blockage in the abdomen, or a leg cramp. The pain of each may be virtually identical.

Where this issue comes up in most cases is when exhaustive evaluation — often involving multiple doctors — fails to identify the cause of a patient’s symptoms. We’ve all heard stories about Aunt Mollie’s stomach pain, which no doctor could figure out — until she died of cancer. We have come to expect, given the highly advance state of medical technology and diagnostic tools, that every symptom or problem we have should be full explainable, and diagnosable. The simple fact is that this is not the case, for a number of reasons:

• Some problems are quite simply very difficult to diagnose: their symptoms are vague or misleading, diagnostic tools are inadequate to pinpoint the problem, or the problem may be a rare or difficult condition unfamiliar or unknown to your physician. This does not necessarily mean your physician is “bad” or “incompetent”–medicine is a vast and complex field, and even a very good internist or family practitioner cannot know everything about every problem. Specialists, on the other hand, tend to know a great deal about their area of expertise and often very little about other fields of medicine. When you see the specialist, and he tells you he cannot find the cause of your problem, he means he cannot find the cause of your problem in his area of expertise. Frustrating, no doubt, but accurate.
• Sometimes the problem is minor–even though the symptoms may be significant. The stomach pain you are convinced is cancer may well be a pinched nerve, a pulled muscle, or something in your diet. Symptom treatment may well be the best approach, as the underlying problem is both self-limited — and very difficult to precisely define.
• Sometimes the problem can be diagnosed, but there is no known cure. Symptom management here may be the best of very limited options — or the only option.
• Believe it or not, the patient can be the problem, rather than the physician. Patients sometimes provide limited or misleading information, withhold critical information due to forgetfulness, embarrassment, deliberate choice, or because they deem it unimportant (it always amazes me when a patient arrives for a visit with a new physician and does not know what medications he is taking!). They demand a pill or a procedure to fix a problem which lifestyle change — smoking cessation, weight loss, exercise, abstinence from drugs or alcohol–will correct. I can treat your arthritis pain with a pill — but losing 50 pounds and exercising may be a much better solution, and won’t give you ulcers or a heart attack. If you refuse this advice, then I may be forced to “treat your symptoms.” And unrealistic expectations also feed the fire: the new “miracle cure” you hear about on the news may make you expect that which medicine cannot provide in your instance.
• Alternative medicine practitioners often castigate the medical profession for failing to treat the right problem–telling you the real problem is a deficiency of this, that, or the other thing. They then sell you expensive and worthless supplements and treatments based on anecdotal testimony and quack science. They never have to prove their claims, and are totally unregulated. Let the buyer beware: if I give you a sugar pill, and tell you its a cure, 10-20% of the times your symptoms will get better: a well-documented fact called the placebo effect.
• Keep in mind that physical symptoms can indicate mental, emotional, social, or spiritual conditions or diseases. A CAT scan will not diagnose the abdominal pain you get from an abusive husband; a brain scan will not find the cause of a headache brought on by a pint of bourbon the night before; your back pain may be worse because you lost your job, or your son got busted for drugs, or your mother-in-law has moved in to stay. And if you never mention these things to your doctor–or if you’re doctor isn’t interested in hearing about them–the underlying problem will not get addressed.
• Lastly, let’s not forget (although physicians often do) that doctors are not gods: we don’t know everything; we make mistakes; misinterpret information; get frustrated and impatient with difficult patients who consume huge amounts of time and energy on vague symptoms and hypochondriacal concerns; get tired and overworked; are distracted by personal or professional problems–in short, we’re humans. Sad but true. Expect otherwise and you will be disappointed. If the problem’s not being found, get another opinion, educate yourself, go to a clinic specializing in difficult diagnoses or challenging problems. And keep in mind: if the last 10 doctors have told you they can’t find a cause for your symptoms, maybe–just maybe–there is no serious problem, and it’s time to simply treat the symptoms–or learn to tolerate and cope with them if they cannot be treated. Sometimes life is hard, and the best medical science has to offer is not sufficient. Hard to swallow, but true in some cases.

So how does this relate to quality in health care? Keep in mind that quality and perception of quality are not necessarily the same. A highly skilled, conscientious physician or team of physicians may evaluate your problem thoroughly and knowledgeably — and still not arrive at an answer to your health problem or symptoms. They have practiced high-quality medicine — but your perception of that quality will be poor, because they cannot figure out your problem. This is one root (of many) of the malpractice crisis: poor outcomes do not by necessity indicate poor quality care. Perfectly-performed surgery may have a disastrous outcome; the correct medication may have serious and unexpected side effects.

Anyway, that’s a long-winded answer to a short question. More later on malpractice and peer review.