Diagnosis – For whom does it serve?

Diagnosis is an important part of healthcare provision. Quite simply, people want to know what’s wrong with them in order to know what can be done about it. Clinicians diagnose so to provide the person living with a disease, the appropriate treatment (Gifford, 2014).

Historically, in musculoskeletal medicine diagnosis has taken the form of identifying the pathoanatomical structure that is responsible for the person’s pain and suffering (Croft et al., 2015).  Diagnosis is important to the practicing physician. Two reasons are firstly, ‘the sense of satisifaction that comes from identifying a diagnosis can be highly compelling in and of itself, because of the “aha” feeling of having risen to the challenge and figured something out’, and secondly, ‘Making a diagnosis can be a powerful aid to clinical reasoning, as it organizes one’s thoughts, lessens the load placed on working memory, and helps to generate explanatory hypotheses for a patient’s situation’ (Ilgen, Eva, & Regehr, 2016)

A lovely perspective paper by Ilgen, Eva, & Regehr, (2016) discusses the unintended consequences of dehumanising patients by overemphasising diagnostic labels and the implications of emphasizing diagnosis as “meaning-making”. Ilgen, Eva, and Regehr, (2016) explain the dehumanising of people to a pathanatomical diagnostic label results in a categorization and clinicians focus on what information is important, filtering out irrelevant “noise”. The overemphasis on the diagnostic label results in a bias towards how patients with a particular disease ‘should present clinically and how they should respond to therapy.’  

I would argue that this aligns with the challenge we have around specific diagnosis versus non-specific, back pain for example fits into both these categories. Now, I would agree that the non-specific label is not a great one, and likely contributes to the perpetuation of suffering. A specific diagnostic label can also have a sinister side as previously pointed out. In his book, Ivan Illic (1976), the Austrian philosopher describes how diagnosis holds a very sinister side. He proposes that the propensity of clinicians to make sense of a disease can lead to diagnostic error as a result of diagnostic bias.  Illic elaborates on the challenges of diagnosis:

‘Diagnosis always intensifies stress, defines incapacity, imposes inactivity, and focuses on apprehension on nonrecovery, on uncertainty, and on one’s dependence on future medical findings, all of which amounts to a loss of autonomy for self-definition.’ – Ivan Illic 1976.

When we consider the natural history of conditions like low back pain, we can see that it is not a condition that you have once and then it resolves for the rest of your life. The evidence base shows that people in their lifetime will have more than one bout of back pain and that back pain can sit on more of a trajectory of change (Kongsted, Kent, Axen, Downie, & Dunn, 2016; Ogollah, Konstantinou, Stynes, & Dunn, 2018). Then of course there is the more confusing research (that ALL clinicians are familiar with and know and love) of asymptomatic findings of pathoanatomical structures on imaging (Brinjikji et al., 2015; Gill, Shanahan, Allison, Alcorn, & Hill, 2014; Van Ginckel et al., 2010). Then we have the research showing how psychosocial factors not physical factors are stronger predictors of disability (Chester, Jerosch-Herold, Lewis, & Shepstone, 2016; Costa, Maher, McAuley, Hancock, & Smeets, 2011; Menendez, Baker, & Oladeji, 2015; Piva, Fitzgerald, Wisniewski, & Delitto, 2009). This is not saying that there may be physical factors involved. However, I feel it begs the question, “So when is something pathoanatomical?” When the clinician who is diagnostically reasoning (not clinically reasoning) deems that it is…?

To circle back to the perspective by Ilgen, Eva and Regehr (2016), they argue that searching for a diagnosis can misappropriately be the ‘goal of thinking’ rather than a diagnostic process as and ‘aid to thinking’

I find this intriguing with respect to what I have previously discussed, as this approach is more about emphasizing the need to understand the patient’s lived experience with their illness. That reducing a person diagnostically to a pathoanatomical source does nothing but serve the clinician that is providing the treatment for said disease.

If we are to be patient-centred then we should be considering it as a multi-dimensional concept. The biopsychosocial model asks that clinicians consider beyond the biomedical perspective (not ignore or disregard it) and consider how psychosocial factors (including biomedical factors) contribute to why the person is presenting in the way they are. Perhaps what we need is a new way of conceptualising diagnosis… That’s for another blog.

To finish I want to leave you with an extract from Ilgen, Eva and Regehr (2016).

‘Instead of placing emphasis on finding the correct diagnosis, learners would be encouraged to hypothesize how their patient’s symptoms might map to what they know about anatomy and pathophysiology, model how they search the literature to find clues for what to do, identify whom they might consult for help, and decide upon a safe management plan before a definitive diagnosis is established. Finally, at the bedside with real patients, thinking of diagnosis as ‘meaning-making’ emphasizes the perpetual importance of curiosity, not only about symptoms, but about the patients themselves, in order to avoid both premature closure and a loss of empathy.’

Thanks for having a read

TNP

References

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., … Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American Journal Of Neuroradiology, 36(4). https://doi.org/10.3174/ajnr.A4173

Chester, R., Jerosch-Herold, C., Lewis, J., & Shepstone, L. (2016). Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2016-096084

Costa, L. D. C. M., Maher, C. G., McAuley, J. H., Hancock, M. J., & Smeets, R. J. E. M. (2011). Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain. European Journal of Pain, 15(2), 213–219. https://doi.org/10.1016/j.ejpain.2010.06.014

Croft, P., Altman, D. G., Deeks, J. J., Dunn, K. M., Hay, A. D., Hemingway, H., … Timmis, A. (2015). The science of clinical practice: Disease diagnosis or patient prognosis? Evidence about “what is likely to happen” should shape clinical practice. BMC Medicine. https://doi.org/10.1186/s12916-014-0265-4

Gifford, Louis. (2014). Aches and Pains. CNS Press, Aches and Pains Ltd, Cornwall.

Gill, T. K., Shanahan, E. M., Allison, D., Alcorn, D., & Hill, C. L. (2014). Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults. International Journal of Rheumatic Diseases, 17(8), 863–871.

Illic, Ivan. (1976). Medical Nemesis: The Expropriation of Health. Pantheon Books.

Ilgen, J. S., Eva, K. W., & Regehr, G. (2016). What’s in a Label? Is Diagnosis the Start or the End of Clinical Reasoning? Journal of General Internal Medicine, 31(4), 435–437. https://doi.org/10.1007/s11606-016-3592-7

Kongsted, A., Kent, P., Axen, I., Downie, A. S., & Dunn, K. M. (2016). What have we learned from ten years of trajectory research in low back pain? BMC Musculoskeletal Disorders, 17(220), 1–11. https://doi.org/10.1186/s12891-016-1071-2

Menendez, M. E., Baker, D. K., & Oladeji, L. O. (2015). Psychological Distress Is Associated with Greater Perceived Disability and Pain in Patients Presenting to a Shoulder Clinic. Journal of Bone and Joint Surgery, 97(24), 1999–2003. https://doi.org/10.2106/JBJS.O.00387

Ogollah, R. O., Konstantinou, K., Stynes, S., & Dunn, K. M. (2018). Determining One-Year Trajectories of Low-Back–Related Leg Pain in Primary Care Patients: Growth Mixture Modeling of a Prospective Cohort Study. Arthritis Care and Research, 70(12), 1840–1848. https://doi.org/10.1002/acr.23556

Piva, S. R., Fitzgerald, G. K., Wisniewski, S., & Delitto, A. (2009). Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome. Journal of Rehabilitation Medicine, 41(8), 604–612. https://doi.org/10.2340/16501977-0372

Van Ginckel, A., Baelde, N., Almqvist, K. F., Roosen, P., Mcnair, P., & Witvrouw, E. (2010). Functional adaptation of knee cartilage in asymptomatic female novice runners compared to sedentary controls. A longitudinal analysis using delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC). Osteoarthritis and Cartilage. https://doi.org/10.1016/j.joca.2010.10.007