Nothing Happens If The Diagnosis Is Wrong

THE PLACE: Medical school, France
THE TIME: 1975

I have survived the “concours,” a competitive examination that I would compare to an intellectual equivalent of “American Gladiators” and through human dissection, the anatomical study of a human who previously walked the Earth.

Now our class is now going to start doing medicine with real, live people.
The excitement is great on our first day of an immense multispecialty class that will take the year, called “Semiologie.” The best English equivalent I can think of is “diagnostic signs.” We each receive notebooks and documents throughout the year that are signed off on by professorial-level clinical teachers who are doctors and have practices.

Every procedure that is part of a physical examination must be “validated,” or initialed or signed off. No, they don’t actually expect us to do it all brilliantly. They would like us to be able to tell when something is abnormal.
We learn about everything from how to listen to heart sounds, sitting in a crowded room where a record player loudly blasts the sound of human heartbeats, to how to do an abdominal exam or even a rectal exam, while an observer stands by us and comments and commands.

Fifteen different medical specialties will be covered, and we must be certified in each.

In an introductory lecture, the point is made that at the end of this year we will not be equipped to make a diagnosis, just to identify signs. Individual diagnoses will be dealt with in certificate lectures, in each specialty.

It was an especially beloved professor, a nice guy who joked and had studied at some places in America and smiled and winked a lot, with those he knew were trying, who suddenly waxed serious and said: “Look, if you ain’t got a diagnosis, and you are treating the wrong thing, the patient ain’t gonna get better. The patient will cling to it as a piece of an identity and won’t much like it if you change your mind, or find a mistake. The worst part, the big problem, will be you as a beginner.” He went on, after scanning the audience. He knew very well we did NOT like to think of ourselves as beginners — although we were.

“As a doctor, you will cling to your diagnosis the way a woman clings to her newborn. You will have thought and worked and produced it, and it is yours, and if some other doctor has a different one or even if it changes, you will cling to it, and you will find it almost impossible to let go. You better do some damned serious thinking before you make this diagnosis, tell it to the patient, and start treatment.”

The proof of the importance of that statement is that I still remember it now.
Fast forward to the 21st century, a typical California county mental health clinic, and a pile of 6 charts is dumped on my desk by some administrative wonkette.

“You’re going to need to change the diagnoses. We can’t bill for the ones you put, so we can’t get paid for those patients. Please change them to something on our billing list,” I do not change diagnoses.

I protest that I never got a copy of the billing list.

“Don’t worry,” I’m assured by the bureaucrat, “I have the categories memorized; just write them down.”

I did, and now I had a list of permissible diagnoses – as well as a growing sense of horror in my eyes.

“Now you can change those diagnostic codes.”

“Only if I made a mistake,” I said, “and I usually don’t make mistakes on diagnoses.”

In response to her withering glare, I added, “I will look at them.”

Not only were there no errors, but I always have a summary of DSM-IV (the diagnostic and statistical manual that serves as the “Bible” of psychiatry) on my desk. I consult it even though I don’t often have to (I got a great memory, and I’ve been dishing out psychiatry for twenty years). Sometimes I show it to the patient and sometimes even photocopy it for them. It gives them a little more confidence to see that I’m going “by the book.” They can see if I’m on the money or not.

The diagnoses in the disputed charts were correct. But the tragic fact is that within the California system – Medi-Cal — the patients would get better services and more help if I changed their diagnoses.

Of course, the bureaucrat’s definition of “better services” is “those we get paid for” – Not what would be best and correct for this particular patient.
This is the way our system works, and it isn’t any different in any of the other dozen or so states that I’ve worked, or in the other systems – be they Army, VA, prison, or even HMO.

It’s not “You get what you pay for” – because you aren’t paying for it. It is “You get what we get paid for – because WE are paying for it.”

“We” being the federal, state or county government, Medicare, the VA, or whatever insurance company you have.

This is the same for the poor people in the so-called “welfare” system and for the people able to afford their own private insurance or if they are covered by an employer’s policy.

The person who pays the bills controls the treatment.

Faced with such choices, I refused in this case – as I always do – to put an incorrect diagnosis in a medical chart. I am the one responsible for this legal document – not the administrator, not the insurance company, not anybody else. If something happens and the patient sues (or the patient’s survivors, God forbid), then I will be the one who is confronted by a prosecutor in front of a judge and jury and asked, “Is this your signature on the medical chart? Are you the one who gave this fraudulent diagnosis?”

I’m a skilled and ethical professional. I told the administrator it didn’t matter what she wanted, the charts were accurate and please take all six of them off my desk.

Word got out that I wasn’t “a team player.” Unfortunately, there are many, many doctors who will sign off on anything put before them and tremble before glaring administrators.

This is the power of a diagnosis. Diagnoses drive payment, insurance, the whole financial system that is all too powerful in current American health care. Diagnosing something like a heart arrhythmia you can see on an EKG is hard enough; even a skin rash you can see can be tough.

Diagnosing psychiatry from a manual is a social and political entity when you have a list of symptoms in a book. These same diagnoses are used when research is designed to test prescription drugs. So I am stuck, I MUST use them when I want to treat a psychiatric patient, when I want to write a prescription in traditional prescription medicine. It is simply the only way to know if I can make them better.

To add insult to injury, most patients remember the date they were diagnosed, citing it like holy writ, and are shocked when I ask them things like “yes, but when did the symptoms start? How did they screw up your life? When did you have to stop work? When did your wife leave?” – or husband, of course.

We know enough about how a body works to ask questions like what process was supposed to be working and when did it stop? Oh, you depleted your serotonin when you did the Rave? Your acetylcholine went lacking when your glucose tolerance got weak? Did you weaken your pancreas in another way; maybe a little too much drinking? It would be better to worry about how that one person tolerated drinking, than to worry about everybody’s threshhold, averaged out and statistically analyzed in published literature. (Of course, I gotta know that stuff, too…)

Instead of thinking about categorizing and norming and what a person has to do to get a prescription or a pension, I have to think about that one person, This is the medicine I was taught to practice, and loved and still love.
A diagnosis may be a list of diagnoses, in various stages of getting proven. Insurances hate this; patients’ aren’t too excited either.

A diagnosis changes with new information, whether it is history remembered or tests ordered and their results known.

A diagnosis changes with the advancement of knowledge, from new literature applied to the patient’s always unique case.

I love doing this like I love solving puzzles (I do.).

I love doing this like I love smiles and thanks from patients (I do).

I love doing this more than any activity in my world.

It is also the medicine that countless government entities have tried to squeeze out of me, in my never ending efforts to take care of patients.

So now that I have my own private practice and I can do anything I want,

I’ve devised a special diagnostic or second opinion service. I’ve recently added it to my home page.

If you suspect that you or someone you love has a wrong diagnosis, please seek out a doctor who can give you an accurate diagnosis so you can receive the help you need.