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EDITORIALS

Received: 11/01/2015

Accepted: 15/02/2015

The diagnosis artifice

“All diagnoses can fit into one patient if you know how to fit them in”.

A student

Alberto Lifshitz

Secretaría de Enseñanza Clínica e Internado Médico, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, México

Communication with: Alberto Lifshitz

Telephone: 5623 2421

Email: lifshitz@unam.mx

The clinical diagnosis is considered the cornerstone in the decisions making process, since it has various functions, including the executive. However, the diagnosis is not only a goal by itself, but a mean to help patients. It is not enough to identify how the disease which ails the patient is called; the diagnosis must be individualized as much as possible in each case, for the mere mention of the diagnosis can mean a wide variety of problems.

Keywords: Clinical diagnosis; Ethics, medical; Patients; Medical education

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This title, concerning nosological diagnosis, refers to the name of the disease to qualify the suffering of the patient, part of an abstraction, an operational and educational construct, but that allows one to ask oneself whether such a disease has its own ontological existence, since it does not exist without the patient, which leads one also to reflect on the nature of disease itself. Of course it exists as a source of suffering and risk of death, but ultimately is an artificial construction for certain purposes: to classify the sick patient, placing them in a certain box in which all are placed who share with them certain characteristics, although they differ in many others; this also allows, based on generalizations, understanding what could have happened, the sequence of events that led to the current state, so we can explain to ourselves as well as to the patient, their family, and colleagues, students. Also, diagnosis facilitates communication with peers so that you can save many more or less wordy descriptions by using the nosological diagnosis as a summary. Finally, it is based on diagnosis that doctors make decisions such as prescribing treatment, performing surgical maneuvers, furthering information with more studies, waiting, watching, and more. In short, the diagnosis has taxonomic, explanatory, referential or denotative, and executive functions.

By becoming a centerpiece of clinical thought, a tendency is identified to ponder the diagnosis too much, when it is believed that the important thing is the name of the disease and not how to help the patient. Indeed, the challenge of diagnosis has an intellectual attraction that other clinical tasks rarely have (it has been called "the art of diagnosis"). It resembles the fascinating police investigation of the classic detective novels, while the disease plays the culprit, the patient is the victim, and the doctor the intrepid researcher who solves the riddle. 

By assigning a name to each disease, a catalog of them is formed (which corresponds to one catalog of remedies and one of causes). For each diagnostic entity, a therapeutic entity. If the patient's symptoms do not correspond to any of the diseases of the catalog, then we face a problem because each person can’t have their own unique disease. Rather, when the name of the disease (nosological diagnosis) is not in the corresponding catalog, their existence is often denied: "You have nothing." This attitude extends to the condition in which the clinician only handles the catalog of their area of ​​expertise, and the judgment becomes: "From the point of view of my specialty, you are healthy" although the patient it is going downhill. Hence the phrase repeated among many patients: "I have nothing, but I don’t feel good."

To do justice to the suffering of the patient, one must, effectively, individualize a complete diagnosis that identifies conditions, not diseases, that does not exclude perceptions, fears, and apprehensions no matter how irrational they may seem, that claims subjectivity and particularizes treatments and prognoses like the proposal that exists of "personalized medicine".

Of course all medical decisions presuppose a diagnosis. Symptomatic diagnosis, upon fully identifying the symptoms and signs, can proceed, for example, to symptomatic treatment (or rather anti-symptomatic). Identifying a syndrome also leads to generic management that does not necessarily mean knowing its cause. But both cases are also devices that guide clinicians’ thinking and behavior. 

Ways to identify a diagnosis include searching for an analogy between the patient's symptoms and those described in textbooks of diseases, or comparing them with the mental images (scripts) that doctors have and that, incidentally, may differ in each one of them. A common strategy is a comprehensive approach that will necessarily encompass, from a long list, the real ills of the patient: if they interrogate and fully explore and do most of the complementary studies available, among this wealth of information will inevitably be the diagnosis, although we must strip away everything superfluous.

A cognitive heuristic that favors biases is the one called anchoring and adjustment. It has to do with early estimation of a diagnosis from the first data and the tendency not to abandon it even though evidence is accumulating against it; supplementary data will be interpreted in terms of the early diagnosis and must accommodate it, sometimes forcibly.

If the issue is achieving a summary expression of the state of a patient, perhaps what has been called "comprehensive diagnosis" (the adjective is quite worn out) fits best to describe reality. The label of the name of the disease alone does not say much about the individual patient. Anyone can identify that not all diabetics, hypertensives, or ischemics are the same as each other, although they share a minimum of features, as there are variables that individualize them: severity, age, patient's ability to contend with their illness, their economic capacity, insurance, social support networks that they have, level of functioning of their organs and systems, tolerance, discipline, adherence, food and nutrition, comorbidities, etc.

Finally, the name of the disease to qualify a condition means, perhaps, a first step and in no way the end of the process, because it has to be refined for the greatest possible individualization. The diagnosis is thus a device to facilitate clinical decisions.

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