Since Sir William Osler’s call for “bedside medicine,” emphasizing compassion for patients, we have been urged to achieve the practice through “evidence-based medicine,” “evolutionary medicine,” and more recently “narrative medicine.” Now an article in the European Journal of Internal Medicine proposes “dediagnosing,” a practice framework for making people feel less ill.
The article’s two Norwegian authors point out that diagnosing constitutes the central part of medical work. It is the most critical of a physician’s skills. Apart from identifying certain conditions, the reason that diagnoses are so important is that our health care system relies on them as wide-ranging indicators predicting, for example, health care attention requirements, preferred selection of treatment pathways, economic compensation estimates, and if applicable, even estimates of sickness benefit requirements. Yet, for the person receiving the diagnosis, it may turn out to be not only a label for a condition, but a source of unanticipated problems. It may influence a person’s identity by inducing stigma or discrimination, and therefore, add to existing physical and psychological problems. It may lead to unnecessary treatments. Some people may pressure their physicians for a diagnosis, others might wish to get rid of it, particularly if it is of a psychiatric nature. Longitudinal studies have also shown that diagnostic errors are frequent and that some diagnostic labels tend to stick with a person often beyond their validity.
There are over 55 000 unique codes or diagnostic categories listed in the International Classification of Diseases. In addition, there is a legion of behaviors, experiences, and social issues that are given their own diagnosis. Opportunities to issue diagnoses are further expanded as some issues in human life become medicalized. The late and controversial psychiatrist, Dr Thomas Szasz (no kin) was particularly critical about giving pathological status to, for example, certain complaints about sexual unhappiness, which would imply that the person or couple is medically dysfunctional in that area.
The theory behind dediagnosing is that a person may be better off receiving an explanation without a diagnostic label. Explanations or discussions would likely reduce the patient’s concerns at the time of receiving a pathologic diagnosis. This practice requires close collaboration with the patient; in fact, in some instances the “patient” label need not be used.
Dediagnosis may also correct or remove a longstanding and stigmatizing diagnosis that has expired. For example, the “you are a diabetic” label is no longer valid when a 60-year-old person who was previously diagnosed as suffering from diabetes mellitus type 2 shows normal test results further to exercise, an improved diet, and weight loss without antidiabetic drugs.
In the words of the article’s authors, “we need dediagnosing to remove diagnoses that do not reduce persons’ suffering and to make them less ill.” It all goes back to Sir Osler’s call to emphasize compassion in our practices.
—George Szasz, CM, MD
Suggested reading
Hofmann B. Looking for trouble? Diagnostics expanding disease and producing disease. J Eval Clin Pract 2018;24:978-982.
Lea M, Hofmann B. Dediagnosing – a novel framework for making people less ill. Eur J Intern Med 2022;95:17-23.
Welch HG, Schwartz LM, Woloshin S. Overdiagnosed: Making people sick in the pursuit of health. Boston, Massachusetts: Beacon Press; 2011.
This post has not been peer reviewed by the BCMJ Editorial Board.
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