0895-4356/90 $3.00 + 0.00 Copyright 0 1990 Pergamon Press plc
J Clin Epidemiol Vol. 43, No. 7, pp. 723-725, 1990 Printed in Great Britain. All rights reserved
Second Thoughts THOUGHTS
ABOUT
RALPH
2525 N.W.
Lovejoy,
DIAGNOSIS
CRAWSHAW
Portland,
OR 97210, U.S.A.
(Receivedfor publication27 October 1989)
To be uncertain is to be uncomfortable, but to be certain is ridiculous
Chinese Proverb
It is the rare physician who has never treated a patient with a disease that defied diagnosis, that is a patient who failed to fit into any of the thousand categories our profession has spun out of the centuries of considering pathology. As a psychiatrist I have had more than my share of patients burdened with symptoms that left them ill with something no physician could identify. Perhaps it is unkind to my colleagues in the other reaches of medicine, but too often when the case defies ready classification, “psychiatric” proves a passport out of the internist’s or surgeon’s office, or worse, direct ticket to the pharmacy. Years ago I treated a benighted young woman for her schizophrenic reaction which readily responded to psychotherapy but concomitantly she developed a persistent itching which “drove her crazy.” She consulted a parade of physicians who quickly fixed on her sometimes erratic speech, her flair for the dramatic, and her insistance that she had something dreadfully wrong, only to confirm my diagnosis, “schizophrenia”, and send her on her way. She remained in treatment with me until her horrible death from a disease which in its advanced stage became obvious as mycosis fungoides. There is little point in castigating colleagues for clinical stupidity, though I still bristle at the indignity and abuse that lady experienced. None of us are masters of enough medical knowledge to “cast the first stone.” The point is to reflect
on some of the many meanings of diagnosis which go beyond nosology, our technical skills, to reflect on the questionable certainty that diagnosis brings to physicians. Assuredly diagnosis is a first step to effective care, if not third party reimbursement. No treatment can be rational without a diagnosis but more is implied by diagnosis than that the physician knows what he or she is about. Consider how a patient without a diagnosis lacks a ticket of admission to the health delivery system. In fact the diagnosis is the primary seal of acceptance into the doctor/patient relationship. For many physicians the lack of diagnosis is too uncomfortable to tolerate and the sufferer is only treatable as he or she becomes a scientific object. For such physicians suffering must be certain, known and measurable. For them medically unidentified suffering in a potential patient is suspect, if only as biosocial disease. Ridiculous as it may seem in our age of enlightened scientific medicine, a patient is not a patient for his or her suffering but as a result of a certified diagnosis. Pain and suffering that fails to measure up to the protocols of quantifiable medical science leaves the person a non-patient, and few are the sufferers who are unaware of the strict rules of admission to medical care. A common biosocial disease is fear of death. TV and the news media are quick to list the disasters and deaths, biosocial catastrophes, that occur to inhabitants of distant places as far 723
124
Second Thoughts
away as Asia or South Africa, or in some cases a little closer to home, say across the river or down the block aways, washed with the cool depersonalization of electronic processing. The public is continually encouraged to deny personal involvement in death. Patients, however, have a different view of personal mortality, for they receive powerful messages, much more powerful than those of the media, messages from their autonomic nervous system that one or more of their organs is in distress. Whether hiccups, itching, fainting, coughing or crushing chest pain, symptoms have a forceful way of obliterating any illusions of immortality, while confronting the sufferer with the possibility that “this is it.” Not that patients generally enter the physician’s office bearing intimations of imminent death. Far from it. Inklings of mortality are usually tucked behind a curtain of denial which generates a curious ambivalence. The denial leaves a hole in reality which the physician is hopefully going to fill with a real, innocuous diagnosis. “My daughter’s father-in-law had a pain like this and it turned out to be too much pepper in his diet”, can be the patient’s proffered diagnosis. The patient’s diagnosis is intended to be a number of things. First, to offer as benign a possibility as possible. In most cases the physician proceeds from here to diagnose “to know” in scientific terms, what the pain is coming from, perhaps gastritis, perhaps an ulcer, perhaps stress with overindulgence, perhaps carcinoma. Rightfully he focuses on the diagnosis. Only when the diagnosis is not forthcoming does another of its elements become revealed. Diagnosis guarantees the patient a ticket of admission to the health delivery system as a genuine, acceptable patient. One possibility all patients face is a lack of diagnosis of his or her suffering and consequent rejection. As it turns out the anxiety patients feel during the introductory contact with a physician is not fear of death but fear of abandonment to the unknown. Initially the patient reaches for something more immediate than rescue from death. The patient not only seeks someone who knows the cause but will also remove the uncertainty which accompanies suffering. At this point in the doctor/patient relationship the nameless can appear more threatening than death. Unidentified suffering carries with it implicit rejection, in the event the symptoms do not add up to something known, how is the healer to
.
relate? Who can heal that which is unknown? The patient is only too aware that if the healer fails to identify the disease, or a satisfactory opening to test for a disease, or someone else who does know, little is left for the healer to do but dismiss the patient, to a deeper unknown. The ultimate unknown in this unhappy chain of events is ostracism from the health delivery system as an unacceptable, as a hypochondriac, as a shirker, a malingerer, a “gamer”. Though the message is subliminal, macho men believe that “a stiff upper lip” reduces the threat of medical rejection. “It is just a pain that starts here in my chest and goes down my left arm. I have had it a hundred times.” Carries an implicit message of “I do not need care. I really can handle this myself so no healer will have an opportunity to turn me down.” Nor is the hostile reaction of the emergency room patient who does not give a “damm” for the diagnosis, “Just fix me up and get me out of here”, far from the denial of the stiff upper lip, macho man. The outburst of the hostile patient can be recognized as a malignant cry of fear; a fear of rejection curiously turned back on itself as a rejection of the potential rejector. Unlikely as it may seem, even children fear clinical rejection, though they must be trained to it by repeated abandonment. Listening to a patient recount the years of pain he suffered as a child from renal colic that went undiagnosed, as no more than hyperactivity, is an education in the profound sense of loneliness that accompanies unshared pain, pain devoid of compassion. Perhaps the most ludicrous form of this subtle rite of passage of patienthood, this labeling for acceptance, surfaces with the news of a new syndrome when medical science announces some new technology for manipulating some hitherto neglected morsel of misshapen anatomy or measuring some expression of homeostasis awry. Once the medical journals’ trumpets blow, a predictable swarm of the “undiagnosed” line up in the hope of redemption as certified sick. Diagnosis is more than knowing the possible pathology of organs. As we climb up and down, in and out of the decision tree of medical knowledge, palpating the diagnostic fruit, none should lose sight of becoming ridiculous in our certainty, of forgetting that for the patient, the great fear is not of bacteria or viruses, but loneliness, even unto death. Our ultimate goal is to treat, always the patient never the disease,
SecondThoughts and treatment starts with the diagnosis. Physicians might consider what we might wish should our personal curtain of denial which allows us to approach death protected from overwhelming dread, our “white-coatedness”, is taken away. In truth we are all mortal and we all can experience a loneliness unto death.
125
With this in mind, I suggest, we would want that diagnosis which will not dismiss us but bind us to the compassionate and caring; that same diagnosis of human uncertainty we make each time we listen to a patient’s symptoms and sincerely join in their search for health.
J Clin Epidemiol Vol. 43, No. 7, pp. 723-725, 1990 Printed in Great Britain. All rights reserved
Second Thoughts THOUGHTS
ABOUT
RALPH
2525 N.W.
Lovejoy,
DIAGNOSIS
CRAWSHAW
Portland,
OR 97210, U.S.A.
(Receivedfor publication27 October 1989)
To be uncertain is to be uncomfortable, but to be certain is ridiculous
Chinese Proverb
It is the rare physician who has never treated a patient with a disease that defied diagnosis, that is a patient who failed to fit into any of the thousand categories our profession has spun out of the centuries of considering pathology. As a psychiatrist I have had more than my share of patients burdened with symptoms that left them ill with something no physician could identify. Perhaps it is unkind to my colleagues in the other reaches of medicine, but too often when the case defies ready classification, “psychiatric” proves a passport out of the internist’s or surgeon’s office, or worse, direct ticket to the pharmacy. Years ago I treated a benighted young woman for her schizophrenic reaction which readily responded to psychotherapy but concomitantly she developed a persistent itching which “drove her crazy.” She consulted a parade of physicians who quickly fixed on her sometimes erratic speech, her flair for the dramatic, and her insistance that she had something dreadfully wrong, only to confirm my diagnosis, “schizophrenia”, and send her on her way. She remained in treatment with me until her horrible death from a disease which in its advanced stage became obvious as mycosis fungoides. There is little point in castigating colleagues for clinical stupidity, though I still bristle at the indignity and abuse that lady experienced. None of us are masters of enough medical knowledge to “cast the first stone.” The point is to reflect
on some of the many meanings of diagnosis which go beyond nosology, our technical skills, to reflect on the questionable certainty that diagnosis brings to physicians. Assuredly diagnosis is a first step to effective care, if not third party reimbursement. No treatment can be rational without a diagnosis but more is implied by diagnosis than that the physician knows what he or she is about. Consider how a patient without a diagnosis lacks a ticket of admission to the health delivery system. In fact the diagnosis is the primary seal of acceptance into the doctor/patient relationship. For many physicians the lack of diagnosis is too uncomfortable to tolerate and the sufferer is only treatable as he or she becomes a scientific object. For such physicians suffering must be certain, known and measurable. For them medically unidentified suffering in a potential patient is suspect, if only as biosocial disease. Ridiculous as it may seem in our age of enlightened scientific medicine, a patient is not a patient for his or her suffering but as a result of a certified diagnosis. Pain and suffering that fails to measure up to the protocols of quantifiable medical science leaves the person a non-patient, and few are the sufferers who are unaware of the strict rules of admission to medical care. A common biosocial disease is fear of death. TV and the news media are quick to list the disasters and deaths, biosocial catastrophes, that occur to inhabitants of distant places as far 723
124
Second Thoughts
away as Asia or South Africa, or in some cases a little closer to home, say across the river or down the block aways, washed with the cool depersonalization of electronic processing. The public is continually encouraged to deny personal involvement in death. Patients, however, have a different view of personal mortality, for they receive powerful messages, much more powerful than those of the media, messages from their autonomic nervous system that one or more of their organs is in distress. Whether hiccups, itching, fainting, coughing or crushing chest pain, symptoms have a forceful way of obliterating any illusions of immortality, while confronting the sufferer with the possibility that “this is it.” Not that patients generally enter the physician’s office bearing intimations of imminent death. Far from it. Inklings of mortality are usually tucked behind a curtain of denial which generates a curious ambivalence. The denial leaves a hole in reality which the physician is hopefully going to fill with a real, innocuous diagnosis. “My daughter’s father-in-law had a pain like this and it turned out to be too much pepper in his diet”, can be the patient’s proffered diagnosis. The patient’s diagnosis is intended to be a number of things. First, to offer as benign a possibility as possible. In most cases the physician proceeds from here to diagnose “to know” in scientific terms, what the pain is coming from, perhaps gastritis, perhaps an ulcer, perhaps stress with overindulgence, perhaps carcinoma. Rightfully he focuses on the diagnosis. Only when the diagnosis is not forthcoming does another of its elements become revealed. Diagnosis guarantees the patient a ticket of admission to the health delivery system as a genuine, acceptable patient. One possibility all patients face is a lack of diagnosis of his or her suffering and consequent rejection. As it turns out the anxiety patients feel during the introductory contact with a physician is not fear of death but fear of abandonment to the unknown. Initially the patient reaches for something more immediate than rescue from death. The patient not only seeks someone who knows the cause but will also remove the uncertainty which accompanies suffering. At this point in the doctor/patient relationship the nameless can appear more threatening than death. Unidentified suffering carries with it implicit rejection, in the event the symptoms do not add up to something known, how is the healer to
.
relate? Who can heal that which is unknown? The patient is only too aware that if the healer fails to identify the disease, or a satisfactory opening to test for a disease, or someone else who does know, little is left for the healer to do but dismiss the patient, to a deeper unknown. The ultimate unknown in this unhappy chain of events is ostracism from the health delivery system as an unacceptable, as a hypochondriac, as a shirker, a malingerer, a “gamer”. Though the message is subliminal, macho men believe that “a stiff upper lip” reduces the threat of medical rejection. “It is just a pain that starts here in my chest and goes down my left arm. I have had it a hundred times.” Carries an implicit message of “I do not need care. I really can handle this myself so no healer will have an opportunity to turn me down.” Nor is the hostile reaction of the emergency room patient who does not give a “damm” for the diagnosis, “Just fix me up and get me out of here”, far from the denial of the stiff upper lip, macho man. The outburst of the hostile patient can be recognized as a malignant cry of fear; a fear of rejection curiously turned back on itself as a rejection of the potential rejector. Unlikely as it may seem, even children fear clinical rejection, though they must be trained to it by repeated abandonment. Listening to a patient recount the years of pain he suffered as a child from renal colic that went undiagnosed, as no more than hyperactivity, is an education in the profound sense of loneliness that accompanies unshared pain, pain devoid of compassion. Perhaps the most ludicrous form of this subtle rite of passage of patienthood, this labeling for acceptance, surfaces with the news of a new syndrome when medical science announces some new technology for manipulating some hitherto neglected morsel of misshapen anatomy or measuring some expression of homeostasis awry. Once the medical journals’ trumpets blow, a predictable swarm of the “undiagnosed” line up in the hope of redemption as certified sick. Diagnosis is more than knowing the possible pathology of organs. As we climb up and down, in and out of the decision tree of medical knowledge, palpating the diagnostic fruit, none should lose sight of becoming ridiculous in our certainty, of forgetting that for the patient, the great fear is not of bacteria or viruses, but loneliness, even unto death. Our ultimate goal is to treat, always the patient never the disease,
SecondThoughts and treatment starts with the diagnosis. Physicians might consider what we might wish should our personal curtain of denial which allows us to approach death protected from overwhelming dread, our “white-coatedness”, is taken away. In truth we are all mortal and we all can experience a loneliness unto death.
125
With this in mind, I suggest, we would want that diagnosis which will not dismiss us but bind us to the compassionate and caring; that same diagnosis of human uncertainty we make each time we listen to a patient’s symptoms and sincerely join in their search for health.
