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Library of Congress Cataloging-in-Publication Data
Names: Kennedy, Ashley Graham, author.
Title: Diagnosis: a guide for medical trainees / Ashley Graham Kennedy. Description: New York : Oxford University Press, [2021] | Includes bibliographical references and index.
Identifiers: LCCN 2021008091 (print) | LCCN 2021008092 (ebook) | ISBN 9780190060411 (paperback) | ISBN 9780190060435 (epub) | ISBN 9780190060442 (online)
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DOI: 10.1093/med/9780190060411.001.0001
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PREFACE
In late June of 2018, Oxford University Press contacted me to ask if I would be interested in writing a book on medical uncertainty, a topic I had written several articles on previously. While honored by their request, I told them that I would rather write a book about the practice of medical diagnosis, which is a topic that I had been thinking and writing about for six years at that time. After finishing a dissertation on scientific models and representation at the University of Virginia in 2012, I had accepted a two-year postdoctoral position at the University of South Carolina in order to devote my time to a study of my newly found passion: the philosophy of medicine. On the first day of my post-doc, I had set myself to the task of mapping out a reading plan of all of the available philosophy of medicine literature on medical diagnosis. I figured that because diagnosis was the starting point of medicine, it should also be the starting point of my postdoctoral reading. Five minutes later, I realized that there was essentially no philosophical literature on diagnosis, and no systematic evaluation of the concepts involved in the process of diagnosing a patient. What a shock! Although there was plenty of interesting
work going on in the philosophy of medicine, at the time it was almost exclusively focused on the evaluation of medical treatments. Most of the medical literature, on the other hand, was devoted either to the specific question of how to evaluate medical diagnostics or to the issue of heuristics and bias in diagnostic practice. I could not find any work—either philosophical or medical—that examined the concepts involved in diagnostic practice as a whole. So I began to study, and to write on, these issues on my own, drawing on my scientific background and philosophical training as well as in-clinic observations at Columbia University Medical Center, while simultaneously teaching these topics to premedical students, medical students, and medical residents at the University of South Carolina and Florida Atlantic University.
Now, nearly eight years later, this book is the result of that work. I do not pretend to have written a book that addresses all of the philosophical or conceptual issues inherent in the practice of clinical diagnosis: The reader will notice that there are many I have left untouched. However, the topics that I have chosen to address are all theoretically important ones that also have direct relevance to actual, everyday clinical practice. While I hope that what follows will be of interest to all medical practitioners, medical students, philosophers of medicine, and patient advocates, I have primarily written it with an audience of medical trainees—interns, residents, and fellows—in mind. As such, philosophers will notice that I do not always give a full defense of the philosophical arguments I present. Instead, I leave that to future work. I hope that in what follows, you will find a work worth reading.
Tequesta, Florida December 2020
ACKNOWLEDGMENTS
I have many to thank for making the writing of this book possible. First, I thank Miriam Solomon, who years ago, after reading a draft of one of my first articles on diagnosis, remarked that, “It wasn’t an article at all, but rather a book.” I have reminded myself of these words on many occasions, and they have served as motivation to see this project through to completion. Thank you Miriam, for your encouragement and support. I am also grateful to Bryan Cwik, Dusty Hardman, Sarah Malanowski, Mark Tunick, and Donna Ray, who generously volunteered to read parts of or, in some cases, the entirety of the manuscript prepublication. Their comments have undoubtedly made the book better than it would have been otherwise. Parts of three previously published articles and two book chapters appear in Chapters 2–5. Chapter 2 contains material from “Evaluating Diagnostic Tests,” published in Journal of Evaluation in Clinical Practice in 2015. Chapter 3 expands upon material from a book chapter published in the 2016 Routledge Companion to Philosophy of Medicine, called “Medical Decision Making.” Chapter 4 elaborates on material from “Managing Diagnostic Uncertainty,”
a cknowledgments
which was published in Journal of Evaluation in Clinical Practice in 2015, as well as material from “Differential Diagnosis and the Suspension of Judgment,” which appeared in Journal of Medicine and Philosophy in 2013. Chapter 5 contains material from a forthcoming chapter, “Imaging, Representation and Diagnostic Uncertainty,” in Philosophy of Advanced Medical Imaging (Springer, 2020). All of the other material in this book is new.
And finally, I am forever grateful for my family—my husband Bobby and my two sons, Micaiah and Kai—who never fail to support me in all of my endeavors—academic or otherwise. I love you.
Introduction
I.1. o V erVI ew
Philosophers have been writing about the practice of medicine for some time. In particular, in recent years, philosophers of medicine have been asking, and seeking to answer, questions concerning both the epistemology and the metaphysics of medical practice. Epistemology, generally speaking, is the philosophical study of the nature and extent of knowledge either globally or in a given domain, whereas metaphysics (although notoriously difficult to define) is generally understood to be the study of the fundamental nature of reality, or what it is that exists. These questions, as they pertain to medicine, are not only philosophically interesting but also practically relevant. Most of the recent epistemological work in philosophy of medicine has been concerned with medical treatments and interventions, specifically with questions about efficacy, evidence, and extrapolation regarding their evaluation. Recent metaphysical inquiry in philosophy of medicine, on the other hand, has focused primarily on the definitions of what counts as “health” versus what counts as “disease” (Engelhardt 1975; Boorse 2013). Yet both of these areas of inquiry in philosophy of medicine have left aside, for the most part, questions concerning the clinical process of medical
diagnosis and the concepts that this process involves. There is a similar gap in the medical literature. Although diagnostics as well as heuristics and bias are extensively discussed in this literature, very little has been written on conceptual issues in the diagnostic process as a whole.
Given the importance of the diagnostic process in modern medicine, these gaps are both significant and surprising, especially because diagnosis is the starting point of the clinical encounter. In fact, before the treatment or prognostic evaluation of a patient can even begin, there must be at least a working diagnosis (and preferably an accurate one). Thus, a critical examination of the diagnostic process, and its prominent role in medical practice, seems to be well worth the effort. This book is meant to begin to address these gaps in the medical and philosophical literatures by engaging with some of the most important and overarching conceptual issues in the practice of clinical diagnosis.
Conceptual issues pertaining to diagnostic practice can be roughly divided into those that concern diagnostic reasoning and those that concern diagnostic testing. Both types of issues are discussed in this book. Furthermore, the methodology that you will find in what follows is an extension of the analytical methods of current philosophy of science and philosophy of medicine. These methods of analysis are not new, but what is new are the questions that I use these methods to address. These questions concern evidence, ethics, and justice as they relate to both diagnostic reasoning and diagnostic testing in the clinical setting.
My own reasons for studying and writing on the diagnostic process are not only academic but also personal. In my early twenties, I became seriously ill and was misdiagnosed, and therefore untreated, for many years. This experience was the cause not only of my genuine intellectual curiosity about diagnostic reasoning and testing in
the clinical setting but also of my reasons for deeply caring about these things. It never hurts to remind ourselves that medicine is always about real people with real experiences, and we should therefore not only study it but also aim to improve it, in whatever ways we can.
I.2. B ook organ IZ at I on and c H a P ter t H emes
The book begins in Chapter 1 with a discussion of the dynamics of the patient–physician relationship, which is the foundation of the diagnostic process, and then moves to a discussion of the question of what counts as diagnostic evidence, as well as who gets to decide. The chapter introduces the interrelated themes of ethics and evidence as they pertain to clinical diagnosis, and these themes, the reader will notice, are continuously woven throughout the discussion in the rest of the book. In Chapter 2, the focus is on what needs to be taken into consideration when evaluating a diagnostic test in the clinical setting. In the chapter, I show that the evaluation of these components—accuracy, clinical effectiveness, and extraclinical value—requires not only scientific inquiry but also philosophical analysis. Accuracy is a minimum requirement that a diagnostic test must meet before we can ask the question of whether or not it is valuable to perform, but even once this is determined, other factors must also be taken into account as well. In particular, when evaluating a diagnostic test, we need to consider more than just a patient’s measurable clinical outcomes. At least in some cases, the epistemic benefits of an accurate diagnostic test can make the results valuable for a patient, even when they do not directly influence that patient’s treatment or prognostic outcomes. In Chapter
3, I discuss the process of diagnostic decision-making (DDM) in the clinical setting, via the evaluation of a specific example which is intended to show that, even in patient cases that might initially appear to be relatively uncomplicated, the process of DDM can be very complex and, in all instances, involves considerations of epistemology, ethics, and probability. Furthermore, the discussion in the chapter highlights the fact that the process of DDM is patient-specific and requires the evaluation of both qualitative and quantitative evidence, as well as a commitment, on the part of the physician, to shared decision-making with the patient. In Chapter 4, I use four case studies, three of which I observed while I was a visiting researcher at Columbia University Medical Center, to highlight and address issues pertaining to diagnostic uncertainty and its management. The cases I chose to examine in the chapter are what I consider to be “ordinary” or routine diagnostic cases, in terms of both the presenting symptoms and the inherent uncertainty in their differential diagnosis. Yet, as the discussion in the chapter shows, an effective management of diagnostic uncertainty must begin with an ability to recognize and acknowledge it in even routine cases in the clinical setting. However, even when diagnostic uncertainty is recognized, this alone is not enough for effective diagnostic practice: It must also be clearly communicated to the patient. In Chapter 5, I discuss the much talked about problem of overdiagnosis (which can in turn lead to potentially costly or harmful overtreatment) as well as the not much talked about problem of underdiagnosis (which can lead to repeated and unnecessary testing and clinic visits). In the chapter, I argue that looking to other forms of evidence, aside from that which comes from diagnostic testing, can help reduce the diagnostic uncertainty that in turn leads to these problems, by facilitating more accurate interpretations of tests conducted in the clinical setting. Finally, in Chapter 6, using the
example of the coronavirus disease 2019 (COVID-19) pandemic, I explore the question of how to balance societal versus individual considerations when diagnostic tests are a scarce resource. As is well known, the purpose of diagnostic testing can be either for the promotion of public health or for the facilitation of the clinical care of individual patients. When diagnostic tests are scarce, we are sometimes forced to rank these, at times, competing purposes. I argue that when doing so, the primary responsibility of the treating physician is first and foremost to her individual patient rather than to the general public at large. For a medical researcher, on the other hand, the priority is reversed. However, because the practice of medicine always concerns the health of individuals, the goal is never knowledge acquisition alone, but instead always also its application.
One theme that I hope will emerge from the interrelated discussions in this book is that within the practice of clinical diagnosis, ethics and evidence cannot be separated, nor should they be. Because the goal of the diagnostic process is not just to acquire knowledge, but instead to also facilitate the health of actual people, it is an inherently ethical endeavor, and not just a scientific one.
Finally, I note from the start that the primary focus of my discussion in the chapters that follow is on questions of evidence, ethics, and justice as they relate to the clinical process of diagnosis. I leave aside the question of whether or not there is a “logic” of diagnosis and, if so, whether this logic resembles other types of scientific reasoning or is generalizable in some way [for a discussion of these issues, see Upshur (2005) and Sadegh-Zadeh (2011)]. I also leave open for others the metaphysical question of what kind of thing a diagnosis is [interested readers might find the discussion of psychiatric diagnoses in Sadler (2005), and Tekin (2016) to be helpful in this regard].
Chapter 1
Setting the Stage
1.1. t H e Pat I ent– PHY s I c I an relat I ons HIP
The starting point of, and the foundation for, the process of clinical diagnosis is the relationship between the patient and the physician. Furthermore, the human-to-human interaction that occurs between a patient and their doctor is, in fact, also arguably the foundation for the entirety of modern medicine. This means that it is worth paying attention to! The relationship between the physician and the patient has both personal and scientific components, which are often intricately intertwined. This is one of the central themes of this book—that science and ethics, as discussed in much more detail in the chapters that follow, are inseparable in medical practice. Thus, in order to most effectively practice medicine generally, and diagnosis specifically, clinicians must at once be concerned with both scientific and ethical considerations.
As with most human relationships, the one between a patient and physician generally begins with an introduction, usually on the part of the physician. Even this simple interaction is important and should be approached thoughtfully. When introducing themself, the physician should state their name and role; using a title is not
necessary. Instead, what is essential is that a professional, respectful relationship is established from the outset. Patients (unless they also happen to be physicians) are not trained in medicine and are therefore not “experts”1 in the field. However, they are in fact equal partners in the patient–physician relationship, and this should be made clear by the physician from the start. Of course, the introduction is only the very beginning of the patient–physician relationship, and many have written extensively on the various ways in which the other aspects of this relationship should be conducted in practice (Emanuel and Emanuel 1992). Approximately 50–60 years ago, the dominant physician–patient relationship model was one of both epistemic and ethical paternalism. The doctor was the pater, whose role was to ensure that the patient received interventions that best promoted their health and well-being. Serving that end, the physician worked on their own, largely without patient input, to diagnose the patient and to choose an appropriate treatment or intervention (ethical paternalism), while presenting the patient only with carefully selected information along the way (epistemic paternalism2). The emphasis of this old-style model of doctoring was on the patient’s health over and above everything else, including the patient’s autonomy. But the problem with this model, as many have pointed out, is that physicians and their patients do not always share the same health goals. Determining what is the best decision in a given patient’s case is not as simple as asking the question of “what is best” for the patient; it also requires asking the question of what the patient wants. And, in some cases, this is not
1. The definition of what counts as an “expert” is highly contested, and I leave aside the discussion of competing definitions here. Interested readers, however, are referred to Douglas (2008) and Watson (2020) for more details on this debate.
2. For further discussion of ethical paternalism, see Croce (2018).
the same thing as what the doctor wants. Because what the patient wants might differ from what the doctor wants, or what the doctor believes is best, it is now recognized that the patient should be able to have input into their diagnostic workup and ensuing treatment plan. This is because “” (Entwistle 2010, p. 1). It is from this nearly universal desire for self-rule that the concern for autonomy in patient–physician interactions arises. Autonomy, simply defined, is “self- governance” or the ability to make one’s own decisions. Another way of stating this is that the term autonomy “typically designates an ability to . . . direct one’s own choices and behaviors based on deliberation and reflection” (Racine et al. 2017, p. 8). In other words, in order for a decision to be considered autonomous, it must be made intentionally and with understanding and be made free from coercion or other controlling influences from the outside. Physicians should be aware that the way that they interact with their patients might either encourage or hinder patient autonomy. In addition to the influence of the physician, patients, like all people, are always located within a complex web of other interpersonal relationships, which can be very influential on their thought and decision-making processes. Some of these relationships support the patient’s autonomy, and others undermine it. This means that determining what the patient wants and needs requires concerted effort on the part of the physician, which can be facilitated by carefully listening to the desires that the patient expresses3 during the clinical encounter.
3. Of course, a patient’s expressed interests might not necessarily coincide with their best interests. Nevertheless, respect for autonomous decisions, even if they are not the “best” decisions, all things considered, is nearly universally agreed to be preferable to paternalism, for reasons stated previously.
1.2. gat H er I ng e VI dence
In order to begin to help the patient, the physician will generally start with the goal of pursuing a diagnosis that explains the cause of the patient’s condition. It is hoped that this diagnosis will, in turn, help facilitate an effective plan for treatment. Many clinicians consider a good (or “gold standard”) diagnosis to be one that proposes a causal explanation, for two important reasons. First, knowing the cause of a patient’s condition facilitates treatment (by allowing for the possibility of intervening on the cause); second, patients tend to both desire and respond positively to explanatory diagnoses rather than diagnostic labels that are not explanatory (Cournoyea and Kennedy 2014). Perhaps surprisingly, patients who understand why they have certain symptoms get better faster than patients who do not have this understanding (Van Ravenzwaaij et al. 2010), likely because understanding can give the patient hope, which we in turn know can significantly improve patient outcomes (Musschenga 2019). Thus, the clinical aim in the diagnostic process is usually to try to find a causal explanatory diagnosis for the patient’s signs and symptoms.
In order to reach this goal of an accurate causal diagnosis, the physician needs to gather evidence. In evidence-based medicine (EBM), which is the currently accepted medical paradigm, the term evidence is a technical one. What EBM proposed when it was introduced in the 1990s was not that medicine should now begin to involve the use of “evidence” (the practice of medicine has always involved “evidence”) but, rather, EBM proposed a new hierarchy of evidence (Evidence Based Medicine Working Group 1992):
Evidence based medicine de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient
grounds for clinical decision-making and stresses the examination of evidence from clinical research. EBM requires new skills of the physician, including efficient literature searching and the application of the formal rules of evidence.
At the top of this hierarchy are randomized controlled trials (RCTs) and meta-analyses, which are considered to be the strongest form of evidence, followed by observational studies, case studies, mechanistic reasoning, and, finally, at the bottom of the hierarchy, expert judgment or clinical expertise, which is considered to be the lowest form of medical evidence. The hierarchy of evidence is arranged in this way with the goal of minimizing bias, or systematic error, when gathering medical evidence, or pursing medical knowledge. The idea is that randomized, blinded trials are less amenable to bias from either allocation or expectation than are observational studies. Furthermore, it is thought that physician expertise might be especially prone to being clouded by biases of various sorts, including expectation biases and interpretation biases that might be based on incorrect or inadequate theories, and thus this form of evidence is ranked the very lowest on the pyramid. Overall, the main emphasis in the proposed method of EBM is on experimental data over and above theory. That is, although all data require interpretation, and therefore theory, at least at some level, when experiment and theory contradict one another, EBM tells us to rely on experiment (and revise the theory) rather than vice versa.
It is important to recognize that for the most part, EBM has focused on evidence for treatments and interventions rather than for diagnoses, about which it has (explicitly at least) relatively little to say. When tasked with evaluating a treatment or intervention, EBM advocates for physicians to look first at what the controlled
studies state rather than at what experts recommend or their intuition suggests. In practice, this means that when an EBM practitioner or proponent uses the term evidence, they are almost always referring to an RCT and not to clinical experience, mechanistic reasoning, patient history, or anything else. However, this view of evidence is far narrower than what the method of EBM actually proposes. Furthermore, if this narrow view of evidence is too rigidly implemented in the clinical setting, it can be problematic with regard to patient care. In other words, if “evidence” just means “RCT,” then there is no “evidence to suggest,” for example, that penicillin is an effective treatment for streptococcus A, that the Heimlich maneuver prevents choking, or that the polio vaccine is effective. But of course we do, in fact, have evidence to suggest that these interventions are effective, and that is precisely because medical evidence is not, and should not be, limited to RCTs. As Braithwaite (2020) notes, “The fundamental problem with [the often-used EBM phrase] ‘there is no evidence to suggest,’ is that it is ambiguous while seeming precise” (p. 2149). Furthermore, he writes that this “mantra for EBM practitioners” can be harmful to clinical medicine because it can “signal to patients, physicians, and other stakeholders that they need to ignore intuition in favor of expertise, and to suppress their cumulative body of conscious experience and unconscious heuristics in favor of objective certainty” (p. 2149). The problem with this sort of method is that it ultimately inhibits shared decision-making and in that way is “corrosive to patient-centered care” (p. 2149).
Because clinical research alone, even in the best-case scenario, never settles health care decisions definitively (Goldenberg 2016), an appeal to a broader base of evidence (one that is not limited to statistical studies) seems to be not only justified but also necessary for effective clinical practice.
Furthermore, a view of medical evidence that excludes both physician and patient expertise and experience completely, whether intentionally or not, fails to recognize not only that important pieces of scientific evidence can be derived from these sources but also that ethical values are inextricably intertwined with every determination of what counts as evidence in any given situation, medical or otherwise. Once touted as the ideal, “value-free” science (and medicine) is now recognized by many as a state that is both unreachable and undesirable. Although those who once advocated for value-free science did so “because they understand values to be ideologically held and immune to rational evaluation” (Goldenberg 2013, p. 4), many now recognize that values can in fact be amenable to revision given empirical evidence and thus that they can be good reasons, not just reasons, upon which to base decisions. So although “there is no rule of logic that can help us decide whose interpretation of empirical experience is the evidence” (Shahar 1997, p. 114), this should not be a cause for despair. In medicine, individual values (on the part of both the patient and the physician) can and should matter in the determination of what counts as evidence.
However, a fundamental misunderstanding of what counts as medical evidence, as well as the role of values in determining this, is pervasive in clinical medicine today. Although foundational papers in the EBM movement (e.g., Sackett et al. 2000) explicitly state that decision-making under the paradigm of EBM should include information derived from experience and intuition, often this does not happen in practice. This is not only a problem with regard to making treatment decisions but also a problem in the diagnostic process because it is often assumed that only the results of diagnostic tests count as “real” evidence and that patient self-reports are unreliable, unhelpful, or even dispensable. However, this is far from being the case: In order to be an effective diagnostician, a physician must be
a pluralist about evidence. That is, the physician must learn to examine all of the available evidence, including the patient’s report of their own symptoms, not just the external evidence of patient signs, such as those provided by diagnostic tests. In fact, qualitative evidence is so important in the diagnostic process that in 80 percent of cases a correct diagnosis can be made on the basis of the patient history alone (Campbell and Lynn 1990). This is truly an astounding statistic, if you take the time to think about it. What it means is that even given all of our technological advances in recent years, the single most effective way to improve diagnostic accuracy in the clinical setting is for the physician to learn how to listen—really listen— to patients because they are the most important sources of reliable diagnostic evidence. This, in turn, requires the use of metacognitive skills, in order to arrive at this level of thoughtful diagnostic work, and care in general.
The activity of listening to a patient, or “taking a patient history,” is a skill that must be honed if one is to become an effective diagnostician. In the first instance, this skill involves learning to refrain from cutting off the patient too quickly when the patient is telling their story. Studies have shown that patients, when asked by a physician to describe their concerns, are interrupted, on average, after only 18 seconds of talking (Beckman and Frankel 1984). This could be due to the worry, on the part of the physician, that patients will go on for too long if they are allowed to talk uninterrupted. However, this concern seems to be unfounded: Marvel et al. (1999) found that patients who were allowed to talk for as long as they needed to, without interruption, spoke, on average, for only approximately 32 seconds—not really very long at all! By allowing the patient to speak uninterrupted, you, the physician, are sending a signal to the patient that you are listening, which sets the tone for a good working relationship. In addition, it means that you probably are,
in fact, listening. If you listen to the patient, they will tell you what is wrong. That does not mean, of course, that the patient will know exactly what they have, how they got it, or how to treat it, but the patient does know what is wrong, and that is the information you must be able to home in on as a physician in order to reach an accurate diagnosis.
1.3. l I sten I ng to t H e Pat I ent: e X am P le 1
Aside from cutting off the patient too quickly, another commonly made diagnostic mistake is to be dismissive of the patient’s history and concerns (Kennedy 2013). There are many reasons why this sometimes happens during the diagnostic process. In some cases, it happens because the patient has a difficult-to-deal-with personality; in other cases, it happens because the patient’s condition is complicated, rare, or otherwise difficult to diagnose. In cases such as these, it can be easy for the physician to blame the patient for their problems—to accuse the patient of hypochondria, malingering, attention-seeking, or self-sabotage. When a physician is not able to immediately diagnose the patient, the physician must be careful neither to place the blame on the patient nor to reach beyond the available evidence in attempting to make a diagnosis. Labeling a difficult patient as a “hypochondriac,” for example, simply because the patient is difficult to interact with is not only rude but also a diagnostic mistake because the proper diagnosis of hypochondria requires the presence of clearly defined clinical findings associated with the condition, not simply that the physician cannot determine what is wrong or is tired of listening to the patient “complain.” Instead of writing off a difficult-to-diagnose patient, physicians must instead be willing to listen carefully to their patients. After all, the patient
is always the expert on their own symptoms. (This is the very definition of a “symptom” after all.) An example, as told to me by an internist in private practice, helps illustrate this point.
A 26-year-old woman with complaints of intermittent chest, abdominal, and leg pain came in to the office for routine care. She had a history of being born prematurely with gastroschisis, which was treated soon after birth. She also had a history of hysterectomy at age 23. Her cardiac evaluation (one month prior) was normal and she also had a negative stress test at that time. Her previous physician had labeled her as a “hypochondriac.” However, an echocardiogram revealed coarctation of the aorta. The patient subsequently underwent vascular surgery to treat this condition and had resolution of all of her symptoms.
Aortic coarctation, or narrowing of the aorta, is generally, although not always, a congenital condition. However, in some cases, it is not detected until adulthood, depending on the severity of the narrowing. Symptoms of the condition include headaches, leg cramps, chest pain, and muscle weakness. Left untreated, the condition can lead to serious complications, such as brain aneurysm, aortic rupture, heart failure, or stroke. In this case, the patient’s diagnosis was missed by the first physician because he essentially dismissed her concerns as “made up.” Why this happened in this particular case is unclear; nevertheless, this example underscores the point that physicians must learn to listen carefully to their patients, in all cases, if they want to be effective diagnosticians. This does not mean, of course, that the physician needs to assume that the patient is correct in their interpretation of, or proposed causal explanations for, their symptoms. That is often (although not always) out of the
