Death of the Diagnosis (As We Know It)
Badges of Despair
I can vividly remember my differential diagnosis professor stating that his class was THE most important class we would take, there may have been many professors that made this same claim. But his reasoning was sound, appropriate treatment can only be administered once the practitioner has narrowed down the issue at hand. This is and always will be true.
With the principle of proper diagnosis preceding treatment it would only make sense that we must properly label each patient with the appropriate ICD 10 classification. Then and only then should the practitioner administer treatment, then the insurance company recognizes the codes input by my staff and then the practitioner gets paid. That’s the way it works, right?
Oh by the way, the patient is feeling better…at least for now.
As a society, now more than ever, we wear labels of illness and injury as a soldier would wear a medal of commendation. We attach these labels to our treatments and prescriptions. You’ve got your Prilosec for your acid reflux, or your Pendalol for your chronic migraines, maybe you have to do your glute bridges in order to wake up those sleepy glutes, and let’s not forget that you can never, ever, under any circumstance bend over again due to your herniated lumbar disc.
Labels cross societal and cultural lines, you may be diagnosed with biliary colic in the U.S., but in China you may told that you have excess Yang. That may lead you to have your gallbladder removed in the West whereas you’ll be prescribed an herbal concoction along with some Qi-Gong in the East. Diagnosis is the language of health care, but the language has become damning and most practitioners are operating with little to no awareness issue at hand.
The diagnosis of illness, pathology and pain is just not that cut and dry. That is why a proper diagnosis should always be considered a ‘working diagnosis’. A working diagnosis entertains the thought that there may be multiple aspects to the chief complaint as well as multiple possibilities and could include a laundry list of comorbidities.
Find Your Waze
The more we learn about all aspects of the human body, the more worrisome the idea of labeling pathology becomes. When exploring the idea of epigenetics, we find that we may not just be a preset code of of A’s, G’s, T’s and C’s, Instead our genetics may work similarly to the algorithm in an app like Waze. Waze might be called ADHD version of Google maps. Waze takes data from other users and various sources to constantly update the route to your desired destination. Whether Waze tries to direct you around a traffic jam or you decide that you would like to take a more scenic route, Waze (or more appropriately the Waze algorithm) will re-direct you as efficiently as possible. This may be similar to how our genetic expression plays out. We have a somewhat predetermined destination that is largely comprised of your maternal and paternal ancestors genetic input over a few generations that has finally been distilled down you…all 46 beautiful chromosomes of you. As we go through life our dietary choices, emotional traumas, physical stress, sleep, etc… all reroute our genetic expression until we are left at a destination that we may not recognize at all.
How does this apply to diagnostic labels?
Well, we now need to consider a scenario such as this.
Mr. Smith goes to see Dr. White because he has been experiencing low back pain for the past two weeks that has not eased up. Dr. White orders x-rays and determines that Mr. Smith has some degeneration of his lumbar spine and is dealing with a bulging or herniated disc. Dr. White, being the 21st century physician he is, prescribes some NSAIDs and muscle relaxers, suggests that Mr. Smith rest for 1-2 weeks and warns Mr. Smith that he should be very careful when bending through his back and he should definitely not be lifting weights or anything of that nature. Mr. Smith is happy to get his bag of pills but he is not so happy that he was told that he should stop working out. Mr. Smith begrudgingly decides that Dr. White is probably right, he reasons that working at a desk most of the day doesn’t really demand too much of him so why continue to lift weights or workout vigorously at all and risk re-injuring his low back?
Fast forward 5 years, Mr. Smith has put on a few pounds and is wanting to start working out again, so he joins a local gym and hires a personal trainer. Mr. Smith is paired up with Johnny Squats, Johnny thinks he can really help Mr. Smith and they start working out twice a week. On their third session Johnny programs some light back squats for Mr. Smith, Mr. Smith let’s Johnny know that he ‘has a bad back’ and that he would rather not do the squats. Johnny soothes Mr. Smith’s worries with some big words and a flash of his own monstrous quads. Well on the second set, you guessed it, Mr. Smith feels a ‘pop’ and has instantaneous low back pain.
He grabs his phone and starts dialing Dr. White’s number as he leaves the gym. Dr. White gets Mr. Smith in and decides that since Mr. Smith is in so much pain that an MRI should be done before they move forward with anything else. The MRI results show multiple levels of herniations and moderate degeneration. Dr. White suggests surgery, Mr. Smith is abrasive to the idea of back surgery, but ultimately he can’t stand the pain so he is put on the schedule to under the knife.
So from that long story, which may be a very familiar one, we have to ask a few questions.
Did Mr. Smith ever really have a bad back?
Does ANYONE ever really have a bad back?
Did Mr. Smith self-manifest his MRI results, whether from a sedentary lifestyle after his initial diagnosis or even weirder yet, from epigenetic changes due to emotional, mental and lifestyle alterations put in motion after his first bout with LBP?
Basically, we are left with the chick or egg scenarios of…was it Mr. Smith’s back that did him in or the label that he bought in to? Obviously this is a hypothetical scenario, but this is an extremely common drama that is played out every day. These questions are very challenging to answer for most people, even though they should still be asked. Especially when making major lifestyle changes or deciding on invasive interventions. As science advances it is my presumption that we will be looking more and more in to things like quantum mechanics, epigenetic cueing and pain neuroscience.
So how can physicians and patients help with this issue as it stands right now?
Physicians: Simply put, tell the patient the truth. Physicians are rarely 100% sure of what the driver of a certain pathology or pain is, but we can surround the issue with plausible agents, we might also call this a working diagnosis (wink*). As a physician you may think this leaves this patient with ambiguity which then causes more distress as they turn to Dr. Google to find out what ‘label’ they have. Here is where diagnostics, not necessarily diagnoses, become absolutely crucial. Proper examination, imaging and testing lead to precise, powerful and timely treatment. When a practitioner can provide care that is targeted at a specific solution without the harm of labeling the person, the results will always be improved.
In addition to the proper diagnostics and treatment, communication is such a large part of the biopsychosocial aspect of treatment that we cannot underestimate it’s importance. Humans are robust organisms, reminding patients that they are not fragile and that in fact they are Anti-Fragile can be very empowering. As Dr. Greg Lehman says…
“be a movement optimist”
… replace ‘movement’ in that quote with human and you cover the entire spectrum of illness and pain.
Patients: Do not settle for a label and a shotgun approach to care. Instead, demand explanation, education and efficacious treatment. The patient is ultimately a consumer and consumers drive a capitalist system…and if you are under any illusion that our medical system is not of capitalist roots then I can firmly give you the real label of delusional. The patient drives the quality of care, so be your own advocate and DEMAND GREATNESS.