To be well is not the same as to feel well.
- N.H. Hadler, Spine, 1996
In our pursuit to "make sure" the patient really has the target disorder (illness), we (the doctors) may be causing the patient harm as they (the not-yet-diagnosed-patient) endlessly work to prove they are not well.
Life is not easy. People confront headaches; muscle pains; sore joints; tired bones; weariness; sadness; neck/back aches; arm/leg problems, and a variety of simple (the common cold) and not-so-simple illnesses (cancer, AIDS) on a daily basis.
So why aren't we not well all the time? A good question, given the daily onslaught of adversities. What allows us to respond, "I'm fine," to the doctor's query, "How are you doing today?" Are we lying? Are we in a state of denial? Are we clueless?
Not! When we say we "feel fine" or "feel well" we actually are referring to our sense of homeostasis, this is, we base our feeling of wellness by how we're coping with the world around us. On those days where our coping skills are overloaded, we report that we are "not doing so well." Generally, we expect the overload to pass us by, or that we will raise our coping skill up a notch or two to deal with the problems at hand. If successful, we return to our homeostasis and report: "I'm fine." Life, once again, moves happily forward.
However, when those days where our coping skills are overloaded turn into weeks and months we stop saying we are fine. At this point we declare we are ill or not-well. Ordinarily, this is not a problem for us. We simply seek out a solution (prayer, counsel, medicine, doctors, etc.) and with a little more effort and the tincture of time we are back in the saddle hollering, "I am fine!" again.
But what of those people who suffer hard-to-believe/pinpoint/diagnose conditions? What happens to them? Do they get back in the saddle as easily? Do they muster coping skills from deep within and pronounce themselves "OK." Or, in their effort to convince those around them that they are actually ill, do they cause themselves to sink farther and farther away from homeostasis?
Present evidence tells us the latter scenario is more likely to occur. These people enter a life of somatizing - a life of dwelling on their physical state as they "study their symptoms" in the belief that with enough study, they can help the doctor figure out what is wrong with them. In essence, they enter a "Contest of Diagnosis."
What is a Contest of Diagnosis?
As doctors, we are taught the patient is not an expert in bodily events - obviously so, which is why we go to such great lengths to become a doctor. The doctor, on the other hand, is trained to examine the illness with questions, examinations, and tests so as to uncover the basis for the patient's predicament. Generally, this process works quite well.
But what happens when the doctor says to patient (who believes herself or himself to be ill), "All your tests are negative"? Obviously, the patient is a disbeliever of the good (but really bad) news. The bad news is quite simple: "Now, I cannot get rid of this problem." Now the contest begins!
Doctor-shopping, treatment-seeking, endless testing and so on are the rules of play in this contest. In this contest, the homeostasis of the ill patient withers in the pursuit of the elusive diagnosis. We, the doctors who have sworn "At first, do no harm," really hurt our patients in this contest. We, more than the patient, have control of the contest - thus their fate.
Resting at the very heart of this dilemma is the role of diagnosis. Should we insist in a confirmation of a diagnosis before initiating treatment? Should we initiate treatment without a definite diagnosis? Do we really need a diagnosis for the patient who is overwhelmed with life's circumstances and complains of aches and pain?
These are not easy questions to answer. Certainly, caregivers must avoid iatrogenicity. Early intervention (and recognition) in some patients may save them from iatrogenic illness behavior.
Do you want to read more on this interesting subject? Then see N.M. Hadler's article in Spine 1996;21(20):2397-2400. Enjoy!
With each article I encourage you to write the questions you may have, commentaries on patient care, or thoughts to share with your colleagues, to me at the following address.
Darryl Curl, DDS, DC
2330 Golden West Lane
Norco, California 91760
Please include your return address.
Darryl Curl, DDS, DC
Norco, California
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