What doctors do when they don’t know the answer

Part two of a series. See also part one.

Previously I’d discussed how most of the time diagnoses are relatively straightforward. But what do doctors do when a diagnosis isn’t immediately clear to them?

Likely one or more of the following:

1. Revert to “novice” thinking. Which, in fact, is completely appropriate. We’re taught in medical school that approximately 90% of all diagnoses are made from the history, so if we can’t figure out what’s wrong, we’re supposed to go back to the patient’s story and dig some more. This also involves reading, thinking, and possibly doing more tests, for which your doctor may or may not have the stamina.

2. Ask a specialist for help. Which requires your doctor to recognize he or she is out of his or her depth and needs help.

3. Cram your symptoms into a diagnosis he or she does recognize, even if the fit is imperfect. Though this may seem at first glance like a thought error, it often yields the correct answer. We have a saying in medicine: uncommon presentations of common diseases are more common than common presentations of uncommon diseases.

In other words, presenting with a set of symptoms that are unusual or atypical for a particular disease doesn’t rule out your having that disease, especially if that disease is common. Or as one of my medical school teachers put it: “A patient’s body frequently fails to read the textbook.”

4. Dismiss the cause of your symptoms as coming from stress, anxiety, or some other emotional disturbance. Sometimes your doctor is unable to identify a physical cause for your symptoms and turns reflexively to stress or anxiety as the explanation, given that the power of the mind to manufacture physical symptoms from psychological disturbances is not only well-documented in the medical literature but a common experience most of us have had (think of “butterflies” in your stomach when you’re nervous). And sometimes your doctor will be right.

A physician named John Sarno knows this well and has a cohort of patients who seem to have benefited greatly from his theory that some forms of back pain are created by unconscious anger. However, the diagnosis of stress and anxiety should never be made by exclusion (meaning every other reasonable possibility has been appropriately ruled out and stress and anxiety is all that’s left); rather, there should be positive evidence pointing to stress and anxiety as the cause (eg, you should actually be feeling stressed and anxious about something).

Unfortunately, doctors frequently reach for a psychosomatic explanation for a patient’s symptoms when testing fails to reveal a physical explanation, thinking if they can’t find a physical cause then no physical cause exists. But this reasoning is as sloppy as it is common. Just because science has produced more knowledge than any one person could ever master, we shouldn’t allow ourselves to imagine we’ve exhausted the limits of all there is to know (a notion as preposterous as it is unconsciously attractive).

Just because your doctor doesn’t know the physical reason your wrist started hurting today doesn’t mean the pain is psychosomatic. A whole host of physical ailments bother people every day for which modern medicine has no explanation: overuse injuries (you’ve been walking all your life and for some reason now your heel starts to hurt); extra heart beats; twitching eyelid muscles; headaches.

5. Ignore or dismiss your symptoms. This is different from the application of a “tincture of time” that doctors often employ to see if symptoms will improve on their own (as they often do). Rather, this a reaction to being confronted with a problem your doctor doesn’t understand or know how to handle. That a doctor may ignore or dismiss your symptoms unconsciously (as I did with my first-ever patient) is no excuse for doing so.

Just which of the above approaches a doctor will take when confronted with symptoms he or she can’t figure out is determined both by his or her biases and life-condition—and all doctors struggle with both. To obtain the best performance from your doctor, your objective is to get him or her into a high a life-condition and as free from the influences of his or her biases (good and bad) as possible.

Alex Lickerman is an internal medicine physician at the University of Chicago who blogs at Happiness in this World.  He is the author of The Undefeated Mind: On the Science of Constructing an Indestructible Self.

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