Blog | Wednesday, July 31, 2013

The symptom or the problem?

"I don't know if I want to take this pain medicine," people have told me more than once. "I want to know what's really wrong with me and not just cover it up." Or: "I don't want to treat the symptoms. I want an MRI because I want to figure out the underlying problem."

There is a dichotomy often used, especially by the people who asked me these questions, between "knowing what's going on" and "not knowing what's going on." The more you think about these categories, of course, the more you realize that these conceal as much as they reveal. If we can determine that someone's lower back pain is not dangerous, but (as in most cases) we will never figure out to what specific tendon or muscle the pain is due to, what does it matter that we might always be in the dark about the cause?

Or take chronic kidney disease, which has recently been reclassified: the cutoffs in kidney function have been changed for some of the categories. Not significantly, but now there are new routes to become diagnosed with the conditions, and new guidelines to treat it. If you had one kind of kidney disease before, and were told, after some tests, you actually had the other one, what was known before and what wasn't? And what difference did it make?

You can never know everything. Treatment has to start sometime. And, since treatment can lead to a better picture of the underlying condition, it's never just covering up what is going on. Treatment and diagnosis always live in the creative ambiguity that is the organic muck of medicine. Sometimes I know what's going on even before a word has been spoken. Sometimes I won't know what's going on even when the patient feels 100% better because of something I did.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins School of Medicine. His research interests include doctor-patient communication, bioethics, systematic reviews, and the role of the primary care provider in cancer care. He is also the author of "Talking to Your Doctor." This post originally appeared at his blog.