Throwaway05
10hr ago
Do physicians generally “know” or feel with a high degree of confidence when they’ve correctly zeroed in on what the problem is?
It depends on the thing, but it is important to keep in mind that for many problems diagnosis is not important (especially in psychiatry). Fixing a problem is important, but a clear diagnosis? Nah. In psychiatry most problems are fixed by an SSRI or an antipsychotic - who cares if they have schizophrenia, schizoaffective, or bipolar disorder if the solution is the same. Who cares what the cause of the hypertension is? Rule out some important things to rule out, and then move on.
Also because the level of specificity - sick, infection, bacterial infection, anaerobic bacterial infection, a specific organism, the specific genetic profile of the specific strain of that organism, all of these are accurate diagnosis, but you can stop early and often should.
So it's hard to answer some of these questions without being reductive or ponderous.
Prions
Our tools aren't magic - for a long time the start of the art for identifying bacteria was dumping dye on it. Identifying something as weird as your own bits during slightly weird shit is hard as hell.
Throwaway05
11hr ago
Now this is my shit right here. How do psychiatrists gauge whether they’re more or less on path to following a proper diagnosis?
Oh boy. This is a long and tough topic. So Medicine is hard. Some people get that some people don't but it needs to be carefully examined.
Some questions are harder than you think, and we don't realize it because we take so much for granted.
So like what is a disease anyway? What is sepsis?
The later is a question still under investigation even though treating sepsis is a core hospital task.
What about a run of the mill bacteria infection? Well turns out usually we are just pattern matching or guessing based off of what died to the antibiotic. An actual culture is useless or impossible most of the time. Spirochetes took forever to identify because splashing shit with these colors we usually use didn't work (yes that's what we do! Random dye!).
A lot of stuff might be an infection and we just don't know yet because who knows what caused it. It's a miracle we figure out prions existed for instance.
So sewing and cutting and surgery is great and all but the noodly thinking bits are an important and interesting part of medicine. Cue nosology.
But you asked about psychiatry though.
That's a further complicated question. The brain is like the most complicated thing in existence, and mental health is the most complicated and multifactorial aspect of medicine.
The specifics become specific, it is why doctors have jobs after all. Some diseases have neuro-chemical markers, brain imaging findings, genetic components and other "hard stuff." This is evolving and of unclear clinical significance.
Sometimes we go off what facilitates communication - depression is hard to define. If everyone including the patients agrees what depression is then you've found it. Sometimes this becomes a cultural negotiation.
Sometimes clinical response is king - if it looks like a duck and quacks like a duck and gets slaughtered by medication like a duck then you got it.
To TLDR it - explaining the specifics of a diagnosis in a thorough way is easy to convey to people in the field who have a shared assumption base, but to people outside of it a lot will be lost in translation and it can look like some stupid questionnaire defines everything.
The rigor isn't what we want but it's more than you fear.
I mean lifestyle interventions are always the first recommendation for everything - lose weight and your BP improves. Socialize and exercise more and your depression improves. People don't do these things so we hit the second line interventions of actual medicine that are a band-aid not a solution.
In the case of SSRIs, if one doesn't work....you just switch to the next thing. Psych has more viable first and second line agents than most disciplines. Even if hit rates are lower it isn't a big deal.
Additionally, depression is more of a syndrome than a disease - shit life syndrome, major depression due to a cardiac problems, classic melancholic depression, all of these things manifest slightly differently but more or less the same and zero percent chance we have a full understanding of the underlying pathophysiology. Shit life syndrome likely responds poorly to medication, but how are you going to define that and separate it for the purposes of research?
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