Category: Ideas

The Double-Edge of Diagnosis

A psychiatrist recently told me, “I have a gift for diagnosing people – I can do it from across the room.” Another psychiatrist, overhearing her, retorted, “Ha! Classic narcissist!”

Doctors are always diagnosing.

Making a diagnosis is central to medical practice. It sets off a chain of events, investigations, and therapeutic treatments, that, ideally, lead to appropriate management. Diagnostic labels help doctors communicate, help researchers keep track of diseases, study the causes of and identify treatments for them. They help patients to explain what they are experiencing to themselves and others.

Diagnosing is essentially pattern recognition – identifying and naming a constellation of symptoms/signs/test results. A study done at MIT showed that diagnosing involves the same brain systems in doctors that are required for recognizing and naming everyday objects.

Which hints at the limitations of diagnostic labels.

If only diseases were as clear cut as objects. As easily agreed upon as, say, a table. A table has pretty much been a table since four legs and a surface were invented. But diseases and their treatments are shaped by the science of the times, the culture we live in, and most importantly, by the people who experience them.

Our brain’s desire to match people to patterns can override our ability to be present and open to uncertainty. Patients with real, but medically unexplained symptoms (MUS) represent some of the most common conditions in medicine. Our lack of understanding of these illnesses has resulted in vague diagnoses of exclusion, such as fibromyalgia, irritable bowel disease, or chronic fatigue syndrome. Our inability to match their symptoms to a more definitive diagnosis leaves these patients in a type of medical pergatory, where they often end up seen as “difficult” patients.

Another problem with diagnostic labels is that, once diagnosed, doctors may see their patient’s disease before their personhood. “The appendicitis in room 3”, “the breast cancer in room 4.”

They can also direct our attention to the wrong symptoms. When my patients are diagnosed with drug dependence, they may get prescribed opioid maintenance therapy as treatment for their “disease”. But if this patient turned to drugs after a childhood where he was repeatedly raped by his father and uncle, is it fair to label him with a stigmatizing diagnosis of opioid dependence? Just because there does not exist a name for the long term effects of chronic abuse? By giving him a diagnosis that puts the onus of responsibility on him rather than on the failure of the system to protect him as a child, it also absolves us of having to pay for services/treatments that address his psychological trauma.

Diagnosing is an inherent part of practicing medicine, but it is important to keep in mind that our diagnostic palette remains incomplete, ever evolving as science advances. It behooves the medical community to take a step back and consider the impact and arbitrariness of our diagnoses.

 

 

Mental Illness? You’re Not Alone. (In Fact, You’re Surrounded).

Prince Harry has had it. Margaret Trudeau has had it. Selena Gomez has had it. I have had it.

By the time we hit 40, 50% of us will have experienced a mental illness. At any given time, it plagues one in five of us. Diagnosed or not, treated or not, affecting you, or someone you love; mental illness takes its toll on everyone.

And yet, stigma (negative attitudes or judgements), and consequent discrimination, is one of the biggest challenges faced by people with mental illness. Stigma is the number one reason why two-thirds of those living with the condition do not seek help.

How can so common an illness be so stigmatized?

By the time I was diagnosed with post-partum depression after my second child, I had been experiencing anxiety and sadness for at least a year. This impacted my relationships, and made mothering, work and even basic decision-making an exercise in exhaustion. It took me too long to seek help, because I was ashamed. To not be enjoying my beautiful life, to not be not coping better with the stress it entailed. I learned that I carried my own stigma toward mental illness. Apparently, depression was okay for my patients to have, but not me. As an emergency doctor, I prided myself on being tough, a super-coper, able to handle anything and climb my way out of any hole.

Turns out mental toughness is not the same as mental health.

Fortunately I stumbled upon an article by Valerie Plame Wilson, a former operations officer of the U.S. CIA, in which she shared her experience of being treated for post-partum depression. I reasoned that if a woman trained to withstand torture at the hands of terrorists could admit to being taken down by this illness, I could too.

man-1394395_640
skitterphoto/pixabay
The misperception of mental illness as a weakness is particularly harmful to men, who continue to grow up with the message that “real men don’t cry”. Kudos to those strong men who are working to smash this stereotype by acknowledging their own battles with mental illness: actor, producer and professional wrestler Dwayne “the Rock” Johnson; retired Lieutenant-General and former senator Romeo Dallaire; and singer-songwriter Bruce Springsteen, to name a few.

The most surprising thing I experienced when I opened up to my friends and colleagues about my diagnosis was how often they responded by sharing their similar struggles. Some were being treated, some were afraid to ask for help, many were self-medicating. I’d had no idea. In being honest with others, people felt comfortable, and often relieved, to share their truth with me.

Untreated mental illness not only affects the person suffering from it, but also has enormous impact on families, workplaces and society. It is critical that we eradicate stigmatization of this extremely common condition, and remove the greatest barrier to people asking for and receiving help.

Until we accept and acknowledge the ubiquity and normality of mental illness, we can never properly take care of our mental health.

 

What helped you get help? If you have not, and need to, what is stopping you? Feel free to reach out to me anonymously by email.

The Humbled Physician

When I was in medical school, my mother, 53 and healthy, had a massive heart attack and ended up needing a heart transplant. By day I donned my white coat and learned the science and practice of medicine. By night I slept on a cot in my mother’s hospital room, observed her cycles of pain and relief, the comings and goings of doctors and nurses, translated and advocated for her. While my medical colleagues and I quizzed each other, and compared procedures, I agonized at the thought of my mother being the guinea pig as we fumbled through our first central line or NG tube insertion. While my attendings chided me for “caring too much”, my mother encouraged me to sit on my patient’s beds, ask them about themselves and how they were doing.

I became painfully aware of the chasm between physicians and patients, science and emotion, medicine and real life. The caring that was missing from health care disturbed me, and left me struggling to make peace with my profession. I considered leaving it, but the fact is, I simply love being a doctor too much, and am grateful for my skills and knowledge of scientific medicine.

I am hoping this blog will be a venue to articulate what is often lacking in the halls of medicine, and to explore ways to fill the void and transform it. To educate and empower patients, to honour our bodies and our journeys through illness. To heal the healers. Ideally this will be a collaborative effort – a tapestry of our stories and ideas – so that we can learn from each other, and, together, create change. Thank you for joining me!

IMG_0020
Queen Elizabeth Park, Vancouver, B.C.