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A Question of Diagnosis

Stephen Carbonara
From an Independent Professional Pharmacist Perspective

Issue 72: June 2008
Page: 1 of 1 Author's Profile | Send to a Friend | Printer Version

Finally the voice of the 65% of non-proprietor pharmacists in Australia is beginning to be heard! The Pharmaceutical Society of Australia (PSA) have provided some level of support for the idea of independent practice by pharmacists within the 'Super Clinic' ideology.
"About time", methinks.
The PSA have finally realised that not all pharmacists are Guild member proprietors.
Now for the BIG test, the Guild has sought an immediate retraction of the PSA's support for independent practitioners.
Let's see if they can stay the course!

All this talk of independent clinical practice now initiates a debate on whether or not a pharmacist can 'diagnose'.
Clinical pharmacists in their practice work closely with illness and disease.
This is either in the practice of medication reviews, hospital ward rounds, QUM consultancy or even when recommending an S3 medicine treatment.
Probably this is more likely to be a broader question of whether or not 'diagnosis' can be performed solely by medical practitioners.
A further question would be: Should a diagnosis be required for treatment?
Or conversely: Should a treatment be initiated without a formal diagnosis?

The word 'diagnosis' is defined by the Oxford dictionary as: the identification of the nature of an illness or other problem by examination of the symptoms.
This doesn't sound overly complicated.
I suppose then we must decide if only a doctor possesses the skills of examination and identification.
How about in the case of a mother with a sick child?
Can the mother diagnose a fever?
She feels the child's forehead and decides, yes, there is a fever.
Has she made a diagnosis, or does she just suspect there is a fever?
Furthermore is 'fever' eligible to be a medical diagnosis, or is it just a symptom?
If it is just a symptom, then how is it determined?
Are symptoms termed to be symptoms because they're obvious?
Are symptoms therefore indisputable?
What if the mother thought there was a fever present however when measured, no fever was detected?
Was the fever therefore wrongly diagnosed or wrongly identified?
BUT the definition of diagnosis (above) IS the identification of the nature of an illness.
Therefore symptoms MUST be able to be diagnosed.

Furthermore, can a symptom be both a symptom and a diagnosis?
For example, the mother diagnoses a fever; the doctor measures the child's temperature and confirms this diagnosis.
The fever is in turn a symptom of the doctor's diagnosis of pneumonia.
The mother suspects her child has pneumonia because the child had a previous hospitalisation for pneumonia, and the symptoms this time were identical.
Had the mother also therefore made a presumptive diagnosis of pneumonia?
Is the mother therefore a (albeit lay) diagnostician?

Let's now extrapolate to pharmacy.
If a patient walks into the pharmacy and shows me a small, circular, red rash on their arm; I might say that it is a ringworm, and recommend they use an anti-fungal cream to treat it.
Have I therefore made a diagnosis of ringworm or have I merely identified a ringworm-esque spectrum disorder?
If my recommended treatment of an anti-fungal cream worked and resolved the rash; THEN was my diagnosis correct or did I fluke-treat a guess-condition?
How about if I didn't know what the small, circular, red rash was; but I recommended they try using an anti-fungal cream based on an appropriate risk/benefit profile instead of having to wait to see a doctor?
If the treatment worked and the rash cleared, does that confirm a diagnosis of a fungal skin infection; or was it a chance resolution of a recklessly treated, self-limiting condition?

One would have to agree that a diagnosis is merely a hypothesis.
Furthermore a diagnosis may only ever appear to have been confirmed when the condition resolves, and even then it may never be totally confirmed as treatments can be similar for different conditions.
A diagnosis is never really absolute.
Diagnoses can evolve over time, change, and may never be accurate.
The concept of a formal diagnosis is an ideal.
In practice, diagnoses may be wrong; but moreover they have varying degrees of accuracy.
For example, a person may be diagnosed as having anaemia based on a haemoglobin level. Whilst this is correct, further investigation may reveal that the diagnosis is more accurately: a megaloblastic anaemia.
However the diagnosis can be further improved if it is discovered that the anaemia is caused by a vitamin B12 deficiency.
Then the diagnosis would become B12-deficiency megaloblastic anaemia.

I would say that diagnosis is not simply that which a medical practitioner believes to be in existence; rather it is more broadly an individual's identification of an illness or condition. Therefore, by extension, a pharmacist may be able to provide diagnoses of illnesses or conditions based on their scope of practice as registered health professionals.

Why then are we afraid to say that we provide diagnoses?
At the very least we do provide informal diagnoses, tentative diagnoses or initial diagnoses.
We don't have to leap across the counter and call ourselves diagnostic experts, but we can diagnose a whole range of uncomplicated medical conditions!
If the medical fraternity is offended by this assertion, I must emphasise that no disrespect is intended.
I merely seek to accurately define the services involved in our practice.
Doctors collectively will probably always remain better diagnosticians than other health professionals, but that should not detract from the fact that 'diagnosis' is not doctor-only-territory!

As for the question of whether or not treatments are diagnosis-dependent, we should remember that a 'diagnosis' is a hypothesis, and that an 'accurate diagnosis' is an ideal.
Whilst in a large number of cases a diagnosis will be able to be confirmed based on the success of the treatment, there will always be a proportion of prevalent of disease that is unable to be characterised.
If we then deny treatment to this proportion of individuals, ...well we're in trouble!
For doctors and pharmacists, it would be great to be able to accurately define every condition that we see, but in all other cases we may also provide treatments based on an appropriate assessment of the risks and benefits of treatment.
This is where therapeutic practice becomes more of an art than a science.

With reference to any future pharmacist involvement in Super Clinics, or indeed in any other independent clinical role; we must be able to accurately define our role.
We will soon start to endure a question of whether or not we should engage in the provision services dependent on protocol-based treatments or diagnosis-based treatments.
I would implore us all to have the professional self-respect and courage to be able to say that we are appropriately autonomous, confident and skilled enough to be entrusted with provision of diagnosis-based services.

Stephen Carbonara.



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