What If You Don’t Need A Diagnosis?

In fee-for-service medicine, a doctor accepts money in exchange for a diagnosis.  This is especially true if health insurance is involved, because without a diagnosis (accompanied by a ridiculously arcane code) the bill won’t get paid at all.  I worry that this exchange is sometimes harmful to patients.

There are some problems with diagnoses.  The first is that they usually lead to treatment, which may or may not be helpful.  It takes a really good relationship with a patient who has a problem to tell him to do absolutely nothing about it, even when that is the best advice he could take.  It’s far easier to write a prescription in the hope that it doesn’t cost too much and helps a bit without causing much harm.  This seems to be what happens in the minute clinics, urgent care centers, and other sources of hit-and-run medical care.

The more harmful thing about diagnoses is that patients often absorb them into their identities.  They start with, “my knee hurts,” are told by a doctor that, “you have arthritis,” and from there go on to conclude, “I am a person with arthritis, and this means that I am always going to have pain that changes my life.”  The diagnosis emphasizes the patient’s disability and dependency, and makes the patient lesser for it.

This is especially true of mental health diagnoses.  You can’t bill for an office visit because the patient is “sad” or “apprehensive,” so doctors diagnose “depression” and “anxiety.”  This creates the expectation that the patient is going to receive an antidepressant or anti-anxiety medicine, perhaps the one that was advertised on television last night.  After that, it is too easy for further office visits to center on the medicine: Does it work?  Are there side-effects?  Should we increase the dose, or try a different one entirely?  It is too easy for important conversations to get lost in managing the diagnosis.

I don’t want to earn a living making diagnoses.  I will use them when they are helpful, just as I use everything else at my disposal.  Sometimes patients come in just because they are confused, or frightened, or unhappy.  That’s not a disease, it doesn’t need a diagnosis, they’re just folks who need some help.


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