Why I Still Start With the Timeline
After all these years, I still start with a simple question: What happened first?
Medicine has become enormously more complicated over the course of my career. We have better imaging, better laboratory testing, better medications, better access to information, and more subspecialty knowledge than I could have imagined when I began. But complicated tools don't necessarily make complicated stories easier to understand.
Sometimes they just give you more pieces.
That is why I still start with the timeline.
EMS taught me that people rarely hand you their story in order. You arrive in the middle of it and begin putting things together. The Army reinforced the habit: establish what happened, figure out what changed, decide what matters now, and act. Medicine added science and experience. Pain management taught me that symptoms don't remain inside neat specialty boundaries, and addiction treatment taught me that sometimes the treatment itself becomes part of the problem.
Astronomy taught me something surprisingly similar.
An orbit isn't defined by one observation. A single measurement tells you where an object was at one moment. To understand where it came from and where it is going, you need observations made over time. You need the sequence, the pattern, and the point where something changed.
A complicated medical history isn't so different.
A single MRI can be impressive. A single office note can sound convincing. A single diagnosis can appear definitive. But none of those things necessarily tells you how the patient got there.
For that, you need the timeline.
Sometimes putting the record in order makes the answer clearer. Sometimes it makes things messier, and that can be useful too. A diagnosis may have been repeated for years even though the earlier records don't really support it. A patient may remember an event one way while records written closer to the time describe something different. A physician may have offered a reasonable explanation that later testing no longer supports.
Those aren't inconveniences to be worked around. They are part of the case.
I have become increasingly suspicious of medical reasoning that depends on ignoring the pieces that don't fit. If your explanation only works after removing the uncomfortable evidence, it probably isn't a very good explanation.
The evidence that disagrees with you deserves attention. Sometimes it changes the conclusion and sometimes it doesn't, but you have to deal with it.
That is one reason I still enjoy complicated record review. There is a detective quality to it, though usually not in the dramatic television sense. More often, it is the slow process of putting small facts back where they belong: a symptom reported in one year, an imaging finding three years later, a response to treatment, a change in work status, a later injury, a spouse's observation, a specialist's note.
Individually, they may not mean much. Together, they may tell you what happened. Or they may tell you that the story you expected to find isn't actually there.
The obligation is the same either way: get the answer as right as you can.
That means resisting the temptation to start with the conclusion. It means being willing to say, "I thought this was going one direction, but the evidence took me somewhere else."
That isn't failure. That is what the work is supposed to look like.
I think that lesson has followed me through nearly every chapter of my life. On the side of the road, you learn to look at what is actually in front of you. In the Army, you learn that confidence is not a substitute for preparation. In medicine, you learn that patients don't always read the textbook. In astronomy, you learn that the universe is completely unconcerned with what you predicted.
And in veteran disability work, you learn that a good medical opinion isn't the one that says what somebody hoped to hear. It is the one that explains why the evidence points where it does.
I have changed jobs, changed uniforms, changed states, gone back to school more than once, spent nights looking through telescopes and days looking through medical records. But the questions underneath all of it have stayed remarkably consistent:
What happened? What changed? What came next? What else could explain it? And does the story still make sense when all the pieces are put back together?
More than forty years after I first began taking care of patients, I still think that is a pretty good place to start.
What happened here?