Symptoms and No Diagnosis.

In Editorial by Edmund Kwok2 Comments

Guest post by James Worrall.

Why is there so much suffering that we cannot explain?

Asked another way, why are there so many symptoms and so few diagnoses?

As an emergency physician, I see many patients who arrive at the hospital with chest pain, abdominal pain, numbness of the extremities, or other potentially worrisome complaints, and yet no cause is found. In fact, I estimate that we only make a diagnosis in one of ten patients with chest pain. When the patient asks me, “What’s causing this pain, doctor?” how am I to respond?

Chest pain is often attributed to gastro-esophageal reflux – heartburn – or it is considered muscular, or perhaps “costochondritis” (a dubious entity). I believe most of the time these diagnoses are just excuses for the fact that we have no diagnosis.

Patients find this hard to accept. Perhaps we are so attached to the philosophy of cause and effect that we believe there must be an explanation for all symptoms; if we could only do the right test, or get the right scan, we would find that cause. But why should there be a cause, a diagnosis, at all?

More properly, there may be a cause, but we have no access to it—no way of knowing it. The cause of the baseball’s flight was the bat which hit it; but what caused you to feel tired one day and cheerful the next? What caused you to fall in love with one person and not another? Perhaps there were many causes, not one sufficient unto itself, and certainly not one as simple as the baseball bat. No single cause, just effects. No disease, just symptoms.

It is an empirical fact that most symptoms we experience are ultimately unexplained. If we could simply accept that frustrating reality, then we would likely get on with the business of treating symptoms and trying to feel better. Sadly we, patients and doctors alike, cannot. Even worse, the presence of unexplained symptoms tends to set in motion a chain of events: more tests, consultations with specialists, and patient worry…all costing time and money. Sometimes, due to inevitable false positive results or physician error, diseases are diagnosed that had nothing to do with the original symptoms! Paradoxically, symptoms have caused disease. Most of the time, no cause is ever found. After this quixotic search, is the patient any better off?

The physician’s dirty secret is that it was usually clear from the beginning that no cause would ever be found.

I believe that this process has the unintended effect of prolonging and exacerbating symptoms. Physicians lack the courage to say to patients that they believe nothing is seriously wrong, the symptoms are benign, and no tests are necessary. They are afraid the patient will hear, “It’s all in your head”. They simply cannot reassure the patient without doing tests, even if they know the tests are probably useless. The subliminal message to the patient is, “I am worried about this”. So the patient worries. The longer the process continues without a diagnosis, the worse things get, the worse the symptoms become.

Whoa! Am I implying that patients imagine their symptoms all along? It’s all in the head? Alas, this mind-body dichotomy is far too simplistic. Any seasoned clinician knows that the patient’s experience of the illness is influenced by far more than the diagnosis: personality, psychology, social circumstances, and other factors we simply cannot identify. And the vast majority of patients with unexplained symptoms are not depressed or otherwise mentally ill.

The only way to avoid some of this misery is to try to connect and communicate with our patients from the beginning, from that first encounter. To accept diagnostic uncertainty. To be patient with our bodies, and to accept our symptoms without always trying to explain them.

A wise physician once told me our first job was to do no harm. Our second job was to relieve suffering. Our third job, if possible, was to diagnose and treat disease. Let us not focus so much on the third that we forget the second, and perhaps ignore the first. Maybe one day we will have a better microscope, a test or a scan to explain all symptoms. Until then we just have our humanity.

Author Bio: James Worrall is an emergency physician and skeptic at the University of Ottawa, Canada.

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Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.
Edmund Kwok
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Frontdoor 2 Healthcare

Frontdoor 2 Healthcare

Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.
Frontdoor 2 Healthcare

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