Diagnosing Patients in the Absence of Data

December 22nd, 2002

To the Editor,

I am extremely embarrassed by the state of medical “science”, having just read the article, “What should we say to patients with symptoms unexplained by disease? The ‘number needed to offend’” by Stone et. al. In this day and age of access to science, technology, history and philosophy, we have come to applaud and publish as research, lessons on how physicians can express their ignorance to patients while taking credit for a diagnosis that neither fully comprehends. It makes for a quicker office visit, certainly, but does not add to the practice of medicine and delays the patient in receiving appropriate care.

Let’s examine the issues at stake in the assumptions raised and advocated by the authors of this “study”:

  1. In the course of their careers, physicians will frequently be at an understandable loss to explain a variety of problems presented by some patients. Technology permits them to measure a variety of structural and biochemical parameters. However, when the “run of the mill” technology has been implemented without definitive implications, doctors must return to “science”. Science is the superordinate category of investigation, to continue the diagnostic process.
    • What parameters have not yet been assessed?
    • What dietary factors and/or environmental conditions exist which might account for symptoms from a toxicological point of view?
    • Patients are eating from an adulterated and unlabelled food supply.
    • They live and work in places where landlords are free to use unlimited numbers of chemicals without notice to tenants.
    • Some nebulous case presentations develop into clearer pictures of pathology over time, as with M.S.
    • What other opinions should be sought, or literature reviewed, prior to reaching the conclusion that a doctor cannot help a given patient?
    • Why not explain to the patient that there may be an organic problem you have not been able to identify along with the possibility that there may be a psychiatric problem to be further explored?
  2. Most physicians are unqualified in the specialty area of psychiatry. It takes more than a stymied physician to justify a patient diagnosis of “hysteria, “functional complaints”, “somatization”, or whatever label is popular these days, that doctors use to close the book on a diagnostic problem. Psychiatric diagnoses should not be misused as a default diagnosis when no other answer leaps out to explain patient complaints. The absence of data does not disprove the existence of a condition. To act upon such an assumption is to do a serious disservice to the evolving field of psychiatry, which needs to work upon its diagnostic protocols in search of positive signs for its various diagnostic categories. Citing the mere “thickness of a patient’s chart” as proof of a disorder is an affront to medical science and the profession of psychiatry.
  3. The patients who participated in this study had neurological complaints. This very nebulous area of symptomotology is often difficult to diagnose. Such signs may herald the presence of an emerging condition, not yet definable. Toxicological issues are also frequently implicated in subtle neurological conditions, while most physicians have only had a few hours of education in these matters during their careers. Here in the U.S., physicians average about six hours of such study in medical school. A further complication is that doctors here are not supposed to accept payment for work-related injuries, and so frequently avoid such avenues of exploration with the patient to avoid complications in their practices. Such cases are frequently characterized by malaise, memory problems, peripheral neuropathy, pain etc. from solvents, pesticides and other poisons encountered in day to day life.
  4. The rate of premature disability is skyrocketing. The Social Security Administration in the USA tells us that 3 of 10 persons entering the work force will become disabled prior to reaching retirement age. The Centers for Disease Control tell us that one in five persons has a chronic ailment generally acquired during their working years. So we have at least half the population showing signs of chronic illness and either leave the workforce or struggle to cope with their problems while continuing to earn a living. In the recent events of the Gulf War, we see between one sixth and one seventh of the healthiest portion of the populatiion succumbing to significant chronic illness.

The human race is simply not not that fragile by nature. We must acknowledge that economic realities have made dangerous technologies available for use by every Tom, Dick and Harry on the planet. We need to admit that the science behind the technology is poorly understood by most of its users. Physicians trying to unravel the broken threads of patients’ lives, who are effected by their individualized responses to the misuse of technolgy or who evidence the early signs of other more well-known diseases, must not be judged in this manner. Every other professional in the world is required to state “I do not have sufficient information to act in this case.” or face the consequences of their actions when they fail, be it a teacher, lawyer, policeman or chemist.

While it is not a popular analogy to compare doctors to members of other professions considered less “august”, it is time to make all professionals accountable for their judgements. The patient who is prematurely judged to have a psychiatric disorder or to be “malingering” will face medical, social, legal and financial penalties that can destroy them and their families.. Physicians must absolve themselves of the need to diagnose ailments in the absence of positive evidence simply because the system implies such a responsibility exists. Appropriate, non-judgmental categories of diagnostic codes must be used in these cases.

Doctors, please change the name of the game to fit the realities of life’s uncertainties. The cost to the patient is unsupportable and does not do credit to either science or the intangible factors of human morality and justice.

Barbara Rubin
New York, N.Y. U.S.A.

Competing interests: None declared

Categories: British Med. Journal

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