Diagnosis is the foundation that treatment is built on.
There are a great many skilled physicians and there are a great many wonderful drugs. Surgeries are becoming more and more delicate. Physician skills and pharmaceuticals have improved tremendously. Yet a precise and accurate diagnosis can still be difficult to come by. For one thing, a precise diagnosis takes time. For another, it takes as much skill — albeit a different skill — as surgery. Otolaryngology, the specialty most closely associated with the voice, is traditionally a surgical subspecialty. In surgical training programs, surgery skills are typically emphasized over diagnostic skills.
However, without the foundation of a precise diagnosis, the best surgeon in the world gets random results. Without a precise and accurate diagnosis, the strongest drug in the world ends up treating the wrong condition. So wonderful drugs and wonderful surgeons require a diagnostician who is both precise and accurate.
Questioning Your Doctor’s Error Rate
In The Black Swan, Nassim Nicholas Taleb advises: “No matter what anyone tells you, it is a good idea to question the error rate of an expert’s procedure. Do not question his procedure, only his confidence.” Most surgeons are reasonably technically adept because they were selected for their manual skills and their training programs are well designed. But even skilled surgeons seem to have a difficult time assessing their own error rate — especially their rate of missed diagnosis.
So even if you are willing to believe in your surgeon’s technical skills, how can you assess his diagnostic skills and his error rate, when even he cannot? As a patient, rather than asking a physician about his error rate directly, the closest I can come to assessing a physician’s diagnostic skill prior to an intervention is to ask myself three questions:
- Do I understand the physician’s explanation of my problem?
- Do I understand why the intervention should correct the problem?
- Do I understand what my physician is uncertain about?
For example: What will taking this pill specifically accomplish? What will abstaining from caffeine specifically change about my symptoms? What are the trade-offs being taken in a decision to have surgery? (There are always trade-offs.)
The Larynx Is a Mechanical Machine
If your doctor gives an explanation you can understand, it is more likely to be a correct explanation. If he makes predictions about your condition that you can test over time, then you can assess the accuracy of his confidence. In laryngology you should be able to look at the video recording of your vocal cords and see if what your doctor says is making sense.
The function of the larynx is simple in that it functions very much like a mechanical machine. It adheres to the laws of physics. It is a valve that opens and closes. It is a pair of strings that vibrate. Consequently, most people can understand the mechanics of the vocal cords. An accurate and precise diagnosis can be translated into easy-to-understand, non-medical terms — and that translation is the key to treatment.
Another caveat: if you feel belittled by your doctor for questioning his judgment, beware. If you have to take the explanation of your physician on faith alone, telling yourself that you are not as smart as your physician, consider the possibility that something is being obscured. Admittedly it is very difficult for anyone to know what he doesn’t know — even for the very bright people who are often selected for medical school. When a physician acknowledges what he doesn’t know, he tells the patient about this gap in knowledge or he refers the patient to someone else.
So, let’s say you have a hoarse voice and want to know more. Read on.