Diagnosis is the Holy Grail of medicine, is it not? Certainly, much of medical school training is aimed at teaching medical tyros how to reach at least a differential diagnosis, if not a definitive one. And in many cases a definite diagnosis can come as a relief to patients, providing a label for what may have been a confusing jumble of symptoms.
But for the experienced doctor, and for many patients, a diagnostic label is just one stage in the illness journey. Cure remains a rarity in medicine; for those with chronic illness, the quality of care they receive as individuals along the route will matter most.
In her latest book, The Imaginary Patient: How Diagnosis Gets Us Wrong, consultant neurologist Dr Jules Montague takes aim at some of the hitherto unshakeable certainties associated with clinical diagnosis. What if your diagnosis is inflected by a doctor’s bias or swayed by Big Pharma? Montague takes the stories of people she has met to illustrate how some patients and their families have had their lives turned upside down by a dubious diagnosis.
“Too often, certain diagnoses have shown themselves to be a form of obfuscation; a repudiation of the search for answers or accountability,” she writes. “The diagnoses foisted upon them sanctioned, even legitimised, unforgivable treatments” — such as the electric shock treatment patient Jeremy was subjected to in the 1970s, following a diagnosis of “homosexual deviancy”.
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In an epilogue, Montague looks at ways to improve diagnostic accuracy; asking who gets to construct our diagnoses; the need to report conflicts of interest by those making a diagnosis; and the interesting concept of de-diagnosis, an annual appointment with a patient where a diagnosis is routinely challenged.
Although patient stories form the spine of her book, the author misses an opportunity to promote stories as a way to improve the care people receive. The discipline of narrative medicine encourages a relegation of diagnostic supremacy while elevating patient experience to the centre of good healthcare, but is not mentioned in the book.
Perhaps the ultimate cure for diagnostic hubris is for doctors to follow the narrative maxim: “Illness is what the patient has on the way to see the doctor and a better understanding of their illness is what they should have when they leave.”
Dr Muiris Houston is a medical writer, health analyst and adjunct professor of medical humanities at TCD
