The importance of a diagnosis to your healthcare
Most of us don’t seek healthcare when we are healthy. It’s when we experience problems (pain, discomfort, impaired movement or sometime a general sense of not feeling well) that we pick up the phone to make an appointment with various health providers. The act of identifying the nature and severity of your health concern based on your symptoms, history, exam and possibly tests is called a diagnosis.
In BC, the Ministry of Health regulates who can and cannot provide a diagnosis under the Health Professions Act and the Restricted Acts List. This ensures that the professional providing your diagnosis must be registered with their respective regulatory authority and also that their profession is permitted to perform the restricted act. Professions including chiropractic, medicine, naturopathy to name some are legally obligated to provide you with a diagnosis for your condition. This is an important procedure to help ensure you receive the right treatment at the right time or a recommendation to consult another practitioner.
So how exactly does a health professional such as a medical doctor, doctor of chiropractic or naturopathic doctor determine a diagnosis? Here are some steps in the process leading to a diagnosis and treatment plan:
1) Symptoms – This is usually the main reason for the visit and what is first described by the patient. Symptoms are any of the physical and emotional changes that are different from your normal patterns, for instance, a painful joint, swollen ankle, a sore throat, stiffness in the back, indigestion, etc. These are the first clue to help understand the problem.
2) Patient History – History can mean discussing what you did yesterday to as far back as what health conditions run in your family. Did you suddenly begin a new activity or sport? Does heart disease run in your family? Have you lost or gained a lot of weight recently? The types of questions you are asked are generally guided by the symptoms you experience.
3) Exam – An exam is critical to determining a diagnosis. This will include looking at the area of your body where you are having a problem and in many cases, the doctor will touch the area. Through touching, they could be looking for swelling, or anatomy that just doesn’t feel right. The doctor may also ask you to perform some basic movements to evaluate your body’s mechanics or to see if the pain, discomfort and stiffness are greater on one side or another. Range of motion will include the spine and involved joints
4) Diagnostic Tests – In many cases your symptoms, history and exam provide ample evidence to formulate a diagnosis but there are some situations where further testing may be beneficial. If a broken bone is suspected, an X-ray is almost always a next step. If there is little evidence MRI or CT scans where appropriate can provide additional information to provide a diagnosis. Referral for lab tests can also guide the treatment plan since some conditions respond well to certain therapies but not others. Making the distinction can speed up patient recovery time or even the right treatment.
Once all of the information on your condition is collected, your doctor will review the findings and provide you with a diagnosis, followed by one or more treatment options. If the practitioner is unable to formulate a diagnosis or suspects a problem that is outside of their scope of practice, they ordinarily refer to another health professional, specialist or in some cases hospital emergency.People don’t usually go with a checklist to their first appointment but it is important to be aware that a diagnosis is a legal obligation that must be fulfilled by registrants of those professions granted this restricted activity. It is also a patient’s right to seek a second opinion or alternate diagnosis if they feel that the one provided to them is not sufficient.