When someone comes to my exam room with a problem, there are three tasks that I am performing for them:

1. Ruling out bad things
2. Making the patient's symptoms better
3. Making a diagnosis

Often people feel that our main job is to make a diagnosis, but it is usually the first on the list (ruling out bad things) that motivates patients to come in.  When the mother comes in with the fussy child, she wants to know if the child has an ear infection.  When the person comes in with severe headaches, they want to make sure it is not a brain tumor or aneurism.  When the person has leg swelling, they want to make sure it is not a blood clot.  As a physician, I always make sure I know what the patient is worried about and address that issue directly.  If I can't rule things out by history (what the person tells me) or exam (what I observe), I order tests to rule them out.

I had a gentleman in the office this morning with upper respiratory symptoms that had gone into his chest.  This progressed and now he was getting short of breath while he was exerting himself.  Now, if this were a 15 year old female, I would have left it there.  The problem was that this was a 45 year old man with high blood pressure, high cholesterol, and a family history of heart disease.  He reported the pain as a "pressure" in his chest and was getting sweaty with it as well as short of breath.  Even though I felt reasonably sure this was not his heart, the fact that on physical exam and history I could not exclude the possibility of heart disease compelled me to order a stress test.  If I felt the likelihood of heart disease was high, I would have sent him directly to the hospital.  Still, it is my first job to rule out bad things, so I did not leave this one be.

I then turned to the second job, making him feel better, and treated what I thought his problem was.  This step is very important for patients to feel that they are being listened to.  They want to know that you have heard that they are sick and are doing something about it.  A lot of times they will just get better on their own, but their expectation is that a medication is necessary.  I honestly think it is important to address the issue somehow, even to give a prescription cough/cold medication. 

This highlights to me the importance of the therapeutic relationship patients need to have with their physicians.  If they have that trust that we are looking after their best interests and they feel we listen to them, we can help them the most.  Without that relationship, there is little that can be done for them.  The main thing patients are asking for when they come to our office is reassurance.  They want to feel confident that if there is something wrong we will find it.  I tell my patients that my job is to worry enough that they don't feel they need to worry.  The worst feeling for a patient is to not trust the doctor and feel they have to do the work themselves.  This does not exclude patients' involvement in their care - it encourages it.  I want to know what they know and what they are feeling.  I want to address their anxieties and answer their questions. 

Once I have done tasks 1 and 2, the third task - making the diagnosis - is not nearly as important.  Who cares what it was as long as we ruled out bad stuff and made the patient feel better?  People don't realize how much of what we do is a "best guess" at a diagnosis, rather than making one.  I will tell my patients "I think you have X" because they need to walk away with something to hold on to.  But the fact remains that actually making the diagnosis is a luxury that often is not achieved.