Tuesday, June 11, 2013
What's your problem? What makes a diagnosis
There has been controversy lately over the new edition of the American Psychiatric Association's new version of their Diagnostic and Statistical Manual (DSM 5). Among a number of critiques, the most-forwarded on the Internet seems to be that of the National Institute of Mental Health, which recommended that researchers applying for grants not use the DSM 5 because, rather than classify diseases and diagnoses based on etiology, it does so based on symptomatology.
The narrative that the psychiatrists are trying to write is a triumphal progression from anecdote to empiricism, from Freud's couch to the colorful images of the fMRI.
Unfortunately, the example psychiatrists would like to follow, medicine, is not as simple as all that. When we diagnose, we often apply a heuristic which relies not just on results of tests and images but also on the patients' symptomatic report. Call it "bacterial pneumonia" all you want, but a patient without symptoms can't be diagnosed with pneumonia even if there's an infiltrate on the X-ray. And even if a patient is symptomatic, we don't go and culture the bacteria from the lung tissue except in relatively serious circumstances.
The point here is not the details of what makes a pneumonia, merely that we do not have a magic on-off switch within the body that we can examine when making a diagnosis. Psychiatrists know this as much as we do, which is why (to internists' secret shame) we don't have anything like a unified diagnostic and statistical manual, and if we did, it would be just as controversial as the DSM.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.
Labels: diagnosis, guest post, psychiatry, Zackary Berger
posted by Zackary Berger, MD at
9:00 AM
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs,
MD
Albert Fuchs, MD, FACP, graduated from the
University of California, Los Angeles School of Medicine, where he
also did his internal medicine training. Certified by the American
Board of Internal Medicine, Dr. Fuchs spent three years as a
full-time faculty member at UCLA School of Medicine before opening
his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical
Student Member, is a first-year medical student at the OUWB School
of Medicine, charter class of 2015, in Rochester, Mich., from which
she which chronicles her journey through medical training from day
1 of medical school.
Auscultation
Ira S. Nash,
MD, FACP, is the senior vice president and executive director of the North Shore-LIJ
Medical Group, and a professor of Cardiology and Population Health at Hofstra North
Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and
Cardiovascular Diseases and was in the private practice of cardiology before joining the
full-time faculty of Massachusetts General Hospital.
Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and
general internist in the Division of General Internal Medicine at
Johns Hopkins. His research interests include doctor-patient
communication, bioethics, and systematic reviews.
Controversies in Hospital
Infection Prevention
Run by three ACP
Fellows, this blog ponders vexing issues in infection prevention
and control, inside and outside the hospital. Daniel J Diekema, MD,
FACP, practices infectious diseases, clinical microbiology, and
hospital epidemiology in Iowa City, Iowa, splitting time between
seeing patients with infectious diseases, diagnosing infections in
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the hospital. Michael B. Edmond, MD, FACP, is a hospital
epidemiologist in Iowa City, IA, with a focus on understanding why
infections occur in the hospital and ways to prevent these
infections, and sees patients in the inpatient and outpatient
settings. Eli N. Perencevich, MD, ACP Member, is an infectious
disease physician and epidemiologist in Iowa City, Iowa, who
studies methods to halt the spread of resistant bacteria in our
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Robert M. Centor, MD, FACP, contributes short essays contemplating
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Suneel Dhand, MD, ACP Member
Suneel Dhand, MD,
ACP Member, is a practicing physician in Massachusetts. He has published numerous
articles in clinical medicine, covering a wide range of specialty areas including;
pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also
authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His
other clinical interests include quality improvement, hospital safety, hospital
utilization, and the use of technology in health care.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about
health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
between teaching medical students and residents, and caring for
patients.
Everything
Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science,
medicine, health and healing in the 21st century.
FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
Internal Medicine Residency and Assistant Dean of Scholarship &
Discovery at the Pritzker School of Medicine for the University of
Chicago. Her education and research focus is on resident duty
hours, patient handoffs, medical professionalism, and quality of
hospital care. She is also an academic hospitalist.
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John H. Schumann, MD, FACP, provides transparency on the workings
of medical practice and the complexities of hospital care,
illuminates the emotional and cognitive aspects of caregiving and
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
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Director for the GI & Hepatology Fellowship Program. He
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I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an
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quality improvement, and quantitative biomedical imaging.
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William Hersh, MD, FACP, Professor and Chair, Department of Medical
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David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
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Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of
hematology and medical oncology. His blog is a joint publication
with Gregg Masters, MPH.
KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites
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MD
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Michael Kirsch, MD, FACP, addresses the joys and challenges of
medical practice, including controversies in the doctor-patient
relationship, medical ethics and measuring medical quality. When
he's not writing, he's performing colonoscopies.
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Elaine Schattner, MD, FACP, shares her ideas on education, ethics
in medicine, health care news and culture. Her views on medicine
are informed by her past experiences in caring for patients, as a
researcher in cancer immunology, and as a patient who's had breast
cancer.
Mired in MedEd
Alexander M.
Djuricich, MD, FACP, is the Associate Dean for Continuing Medical
Education (CME), and a Program Director in Medicine-Pediatrics at
the Indiana University School of Medicine in Indianapolis, where he
blogs about medical education.
More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice
internist, returns with "volume 2" of his personal musings about
medicine, life, armadillos and Sasquatch at More Musings (of a
Distractible Kind).
Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
musings on medicine, medical care, the health care system and
medical ethics, in no particular order.
Reflections of a Grady
Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being
a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka,
MD, ACP Member, is a board certified rheumatologist in St. Paul,
Minn. He was a chief resident in internal medicine with the
University of Minnesota and then completed his fellowship training
in rheumatology in June 2011 at the University of Minnesota
Department of Rheumatology. His interests include the use of
technology in medicine.
Technology in (Medical)
Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
education, social media and networking, practice management and
evidence-based medicine tools, personal information and knowledge
management.
Peter A. Lipson,
MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
around in various forms since 2007, offers musings on the
intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice
Boughton, MD, FACP, practiced internal medicine for 20 years before
adopting a career in hospital and primary care medicine as a locum
tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD,
FACP, is an internal medicine physician who has avidly applied
computers to medicine since 1986, when he first wrote medically
oriented computer programs. He is in practice in Tacoma,
Washington.
Other blogs of note:
American Journal of
Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.
Clinical
Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP
Member, associate program director at New York University Medical
Center's internal medicine residency program. Faculty, residents
and students contribute case studies, mystery quizzes, news,
commentary and more.
Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.
PLoS Blog
The Public Library of Science's open access materials include a
blog.
White Coat
Rants
One of the most popular anonymous blogs written by an emergency
room physician.
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