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.

 

 

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!

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Queen Elizabeth Park, Vancouver, B.C.