Trog Blog #9: A Mexican Standoff–Subjective vs. Objective vs. Patient Reported Outcomes

“When you don’t know what exactly is going on, look for discrepancies and start treating there”. I said that a lot in May.

I’ll offer a cookbook style recipe for getting to the root of matter when evaluating patients:

1. Continuously ask yourself: “does this make sense?” Or “does this all match-up?”

2. Administer a patient reported outcome (PRO) measure. I prefer the PROMIS because it gives you the patient’s perception, across multiple domains of health, in a non-disease-specific way. It’s obviously the best PRO out there. But if you don’t have it, your manager won’t buy it, or you like dwelling in caves, use any PRO. The point is–get the patient’s perception without any input from YOU.

   1. Does this make sense?

3. Do a chart review & do some profiling. Yes, I said it. It’s okay to profile people within a musculoskeletal evaluatory context! You know that middle aged people are more likely to present with different problems than adolescent girls than MMA fighters. Just keep your profile flexible as you get more data.

   1. Does this make sense? 

4. Patient stories are important. In fact, I would argue they are the most important part of any evaluation. And if you listen well, stay quiet except for a few targeted questions, and remain patient during the patient’s story, you’ll get about 80% of your diagnosing done without doing a single test. [This will be a topic for another Trog Blog].

   1. Does this make sense?

5. At this point you have a PRO & a subjective examination. You should have 90% of the data you need to make a diagnosis; or at least have it narrowed down to a few ideas. BUT DON’T SHOW YOUR CARDS! You still need to do an objective examination to make sure you didn’t miss anything. You also need to confirm and refute your differential diagnosis up to this point. And BONUS POINTS you can use the objective examination as non-verbal communication (remember the Bayesian Statistics thing in Trog Blog #3?)--like when you push on someone’s back to show them it is strong, or you do forceful knee ligamentous testing to show them their ACL isn’t torn, or have someone jump around the clinic to show them that their ankle isn’t broken!

   1. Lastly, does this make sense?

What you have done is the “Mexican Standoff” from the title of the blog. You pit the PRO against the Subjective Examination against the Objective Examination.

If they all match? You’re good to go. It’s probably a straight-forward case.

If they don’t match, then you need to do some digging–maybe you need to do a better objective examination. Maybe you need to ask better questions. Maybe you need to change patient perception because they perceive themselves differently than their tested capabilities reveal.

It can get nuanced quickly. And it often takes a few visits to get to the bottom of it. But don’t be dismayed! It is better to labor in the discrepancies than ignore them for 20 visits, wonder why the patient isn’t getting better, blame the patient for not doing their exercises, and then discharge their case…

Use the 3-way standoff to your advantage…and don’t live in caves…