Differential Diagnosis

A patient on Monday was inquiring about whether an MRI was needed for an upper extremity issue and I was put on the spot with no Dr. Roberts in sight. It was an interesting situation to be in because the patient had been suffering from chronic pain for awhile and was searching for an answer as to why.

Thankfully, the question was raised after I finished doing some soft tissue work because I was able to show the patient the change in range of motion and reduced pain. I was pretty confident in what was going on and felt as if an MRI was not needed. If the therapy was not successful and there was a lack of work related movements tied to the injury, then perhaps, imaging could have been a good idea, but the therapy was successful and there was also a history of repetitive trauma to the extremity.

After writing the last blogpost about massage versus chiropractic, I began wondering why folks choose massage over chiropractic and vice versa. One thought was that under the massage therapists care, a person can passively receive treatments without worry. It is a really beautiful way of applying soft tissue therapy because the patient feels as if they are taking care of themselves proactively and accepts a treatment. The patient can relax and the skilled person can relieve aching muscles and calm the mind's negative injury mechanisms. Blood flow can be restored and new tissue is built a few days later that is in better working order than before. Our chiropractic work is no different for some. However, there is a negative association with DC care because we diagnose and adhere to rigid treatment plans. It becomes a problem focused approach. I think this is why many DC's move toward the wellness end of the spectrum versus the medical end of the spectrum.

As chiropractors, we do the same thing as MT's, just quicker. Granted, at times, massage is the best choice for care because the fast approach is either not tolerable or it just doesn't work. A friend of mine shared a story recently that suggested our health care system for musculoskeletal problems is flawed. I can't share the story in it's entirety, but I can say that I agree. We are being taught to rule in or rule out pathology in order to decide if chiropractic care is the best approach for the patient's problem. Our MD and DO counterparts are taught the same exact thing in school and guess what, they screw it up too sometimes. My friend's story outlined the main problem with seeking care as a money-focused issue. Meaning, there is such a demand to make money that good quality health care is lost in the process. Dozens of practitioners later and thousands of dollars lost, the patient ends up at a massage therapist's office and gets better. We chiropractors are perfectly set up to NOT miss musculoskeletal problems like this.

Here we are slaving away at learning how to formulate a differential diagnosis list for every patient, learn orthopedic and neurologic exams and screen for visceral/organic disease and we can't figure out a musculoskeletal problem? This is called a huge waste of time for everyone and etches a deep wound on our profession as well as the big brains in medicine.

I tend to wonder if patients get caught in the mix of things because assumptions are made by doctors based on what pays the bills. Or if the doctor doing the diagnosing, practices with a limited toolbox, such as using high-velocity adjusting only for all problems.

The hardest part of being a chiropractor is knowing when NOT to adjust a patient. We are taught to use high-velocity thrusts from day one in our program as our number one tool, so going against this engrained truth is challenging. Recognizing the problem that responds well to adjusting is not easy and takes many, many years to learn and the same can be said about the problem that doesn't respond well to adjusting.

Our differentials consist of many different diseases and conditions that can be identified with proper orthopedic exams, neurologic exams and palpation. Even our joint restrictions can be found with this approach. The misses that happen, such as my friends, are really due to poor quality in assessment. I know we will all miss things in our careers, but we are paying a ton of money to not miss things and we will pay with our reputations if we do. On a side note, this is why I will be referring for all radiographic imaging versus investing into an in-office set up this year.

The going joke is that all chiropractors are poorly trained and are mostly concerned with draining your insurance versus actually taking care of your problem. I want to stop this generalization. The crappy thing is that we all need to eat and pay the mortgage. So, who can you trust for your health needs? Do you trust the highly educated doctors or do you trust the more passive approaches to care? I hope the answer is the highly educated doctors because they are trained to rule in or out serious disease. The issue is, how do we minimize the misses, particularly when the problem, such as my friends, was a perfect case for conservative musculoskeletal care.

Always be present (as Dr. Roberts says).

All for now