I received an email from an old friend who was recently fortunate to retire. Unlike those mentioned recently in Why We Lie (September 2019), this friend seems to be relishing the new role. In all of my years in this community of Worker’s Compensation, I have seen so few individuals successfully retire completely. It’s probably a symptom of the kind of people that become involved in such a people-intensive career path. They are committed, dedicated, and relentless. They seem to always simply find some other way to be involved. Retirement is such a challenge.
The friend related to me renting an apartment to have an extended visit with family. Upon moving in, they found "a few maintenance issues," including lights that did not illuminate as expected. They summoned the maintenance department, which turned out to be a sophomore student at a local university. It is heartening to hear that students still work during college; it takes me back to my days delivering pizza, in the snow, uphill, both ways (you get the picture).
The student in this story was presented with a "large plastic storage box" that was "filled with all types of bulbs." The student expressed hope that some of those would be appropriate, but admitted she/he had "actually never changed a light bulb before." Some will question how one reaches adulthood having never changed a light bulb. With some minimal help, the student managed to select an appropriate bulb and replaced the bulb in one of my friend's light fixtures. The new bulb did not illuminate either. Thus, a dilemma. Is the new bulb faulty or is the light fixture? The student was apparently at a loss to differentiate.
My friend directed the student to a lamp with an illuminated, working bulb (that was thus known to work), removing that bulb, and trying the new bulb in that lamp. The new bulb did not work in that lamp, and thus they concluded together that the new bulb was faulty. The student "correctly concluded she/he needed to try another new bulb and started to put the first one back in the storage bin." The friend suggested that instead, the student should just dispose of it so that it would not have to be similarly tested again (sound planning). Thereafter, the student worked through the various non-functional lights replacing each with working bulbs.
The description of the process reminded me of the differential diagnosis that is used by doctors in reaching a diagnosis. As Merriam-Webster defines: "the distinguishing of a disease or condition from others presenting with similar signs and symptoms." You see, with the symptom being the bulb emits no light, there are a variety of potential explanations. One is the bulb is faulty, the other is the fixture is faulty, and yet another is the power source to that fixture is being interrupted. Each would cause the no light, but knowing the potentials merely begins the analysis.
Using this process, a physician can begin to eliminate potential causes of symptoms, until she/he arrives at a conclusion. As Healthline puts it, the physician makes the list of potential diagnoses, and "may then perform additional tests or assessments to rule out specific conditions or diseases and reach a final diagnosis." It is perhaps similar to Michelangelo's quote regarding how he sculpted David: "It is easy. You just chip away the stone that doesn’t look like David." The student with the light bulbs did that, even if it was not labeled a "differential diagnosis." There is some level of common sense to the light bulb process. While the medical diagnosis process may involve sophisticated testing and expertise, the logic path itself is similarly somewhat common sense.
The friend noted that the moral of this light bulb story is perhaps that colleges "don't teach that skill" (light bulb changing). Or, more specifically, the moral may be to teach your children how to change a light bulb before they go to college. This reminded me of a Bloom County cartoon decades ago in which one character, "Binkley, asks his dad what the phrase 'to wind one's watch' means." Perhaps bulbs just don't wear out that often anymore? Or, are we providing too much shelter to this next generation?
The process with the light bulb is reasonably straightforward. But, admittedly, the human body is far more complex. Various medical websites stress that a critical element of the differential diagnosis is obtaining a history from the patient (what are the symptoms, when did they start, etc.). The importance of that is likely self-evident. But, a publication on the website of the National Center for Biotechnical Information expands on the importance of information.
This 2013 article stresses information gathering is enhanced when the process is infused with a relatively simple addition: empathy. The conclusion is that empathy with the patient increases the probability that the patient will be satisfied with the outcome of the doctor/patient interaction. The authors concluded that doctor training should include both the development of "clinical reasoning and empathy," which the authors say "are two sides of the coin of history taking."
Thus, there is a process for sorting through various symptoms and complaints and reaching a differential diagnosis. But, that may not be a deferential diagnosis. Should care, or a referral to another physician, be rendered or denied based solely upon deference to the feelings or wishes of the parties? The Florida First District Court has addressed this in Carpet Shop v. Vance, 542 So. 2d 1039 (Fla. 1st DCA 1989). There, the Court explained that treatment or care decisions should be based upon what the physician believes "in the exercise of his own judgment and not at the request of" the parties. In other words, the diagnosis and conclusions should be of the physician.
The judgment of the physician was later reiterated by the Court in Rolle v. City of Rivera Bch., 826 So.2d 1075 (Fla. 1st DCA 2002). There, the authorized physician made a referral for an evaluation when an injured worker suffered chest pains during therapy. The Court explained that the doctor's decision authorized the exigent care and testing. Again, it was the physician's belief of the necessity of that care that mattered.
However, in Twin Cities Hosp. v. Cantrell, 894 So. 2d 1038 (Fla. 1st DCA 2005) the Court noted that a prescription for an evaluation is not sufficient to demonstrate that such is either "medically necessary" or "causally related." The Court noted that "an employer is to provide benefits “only to the extent that an injury arising out of and in the course of employment is and remains the major contributing cause of the disability or need for treatment.” Therefore, though the doctor wrote a prescription for evaluation, the employer was not obligated to provide it absent this connecting conclusion of medical necessity and relationship.
The process of differentiation is critical to the diagnosis process, while deference is appropriate to the process and opinions, but not necessarily to the parties involved.
