This section explores the traditional doctor-patient interaction in the context of regional musculoskeletal illness and from the perspective of the treating physician. However, as was emphasized in Section I, it is a fellow human being who is entering into the patient-physician contract and who will forever be changed by the experience. To care for any patient, the physician must become and remain cognizant of the process that led the particular individual to seek medical care in the first place. The physician must realize the perturbation of the illness that is intrinsic to the diagnostic process. Awareness of preconceptions and expectations, and empathy and support for the individual assuming the patient role are as important as the diagnostic process itself. If the diagnostic process leads to a curative therapeutic outcome, a clean break of the doctor-patient contract becomes reasonable and likely. The patient walks away from the interaction as a well woman or man who is likely to burnish the memory with a sheen of gratitude. However, if the process generates no definitive solution, the contract is maintained and the therapeutic nature of the ongoing relationship will depend heavily on the caring quality of the process from its initiation. For regional musculoskeletal illness, this latter circumstance is the rule.

The patient-physician contract is familiar: The patient is made to display his or her illness to generate the first level of diagnostic hypotheses. These hypotheses are tested by physical examination, and the possibilities are pared. The next level of hypothesis testing takes advantage of the clinical laboratories, imaging technology, and specialized testing such as electrodiagnostics. The efficiency of the process relates to the precision with which hypotheses are tested; each test must be chosen because of a high likelihood that the result will answer a specific question. The utility of many of the tests that are commonly used in attempting to diagnose regional musculoskeletal disorders, including those performed as part of the physical
examination, is known. Many tests turn out to provide little meaningful information and should be relegated to history. After all, the diagnostic exercise degenerates if the tests are inaccurate or the results are nonspecific. The application of indeterminate testing is a reproach to the diagnostician and an assault on the coping mechanisms of the patient. As will become clear, much of the testing to which the patient with a regional musculoskeletal illness is currently subjected qualifies for this condemnation.