A week or two ago I was challenged by the suggestion that ‘GPs need a lot more guidance on how NOT to diagnose people’. The claim came from a nationally renowned clinical psychologist and it got me thinking as to how the making of a diagnosis might be detrimental to how we manage patients. Though the comment was perhaps directed most specifically to the management of those who come to us regarding their mental health, it is worth considering how applying a diagnostic label to any individual, whilst being helpful to the clinician, may be harmful to the patient. Having categorised a patient as having a certain condition, the clinician finds it easy to apply the corresponding, off the peg, management plan and is helped to feel comfortable in what they are doing. The patient, however, whose unique individuality is liable to be lost as a result of the label being applied, can end up being offered less personal care as a consequence of a one size fits all approach. Furthermore, because of the way we think, once a diagnosis is made it can be difficult for us to change our mind. This is, of course, particularly important if our original diagnosis is wrong.
Back in my undergraduate days I intercalated in psychology and wrote my dissertation on stereotypes. Stereotypes are cognitive structures which are used to take short cuts to determining how we might best act and feel in uncertain situations. Thus if we see a hooded individual brandishing a knife as they approach us in a darkened alley, though we may not know anything about the individual in question, we might understandably jump to a stereotypical conclusion as to how we might expect that individual to act and thus we may be prompted to make good our escape. On the face if it, therefore, one might be forgiven in thinking stereotypes are good and helpful but it’s a bit more complicated than that. Firstly stereotypes can be formed despite having no basis in fact. Take, for example, the ‘illusory correlation’. The idea here is that when two uncommon occurrences occur together, the combination is particularly salient to those watching on and are thus deemed to occur together more prevalently than is actually the case. So, for example, if a rare occurrence, such as some form of antisocial behaviour, is seen to have been committed by a minority group, then that minority group can easily be perceived as being disproportionately responsible for that antisocial activity. One can see, therefore, how stereotypes can lead to unfounded beliefs being held about those we know little about which can, in turn, result in inappropriate prejudice towards out groups.
Furthermore stereotypes are very difficult to change once formed. If stereotype incongruous behaviour is witnessed, the tendency is to explain away the anomalous activity in order to maintain the belief that the stereotype is valid. Far be it for me to suggest such a thing, but were we to hold, for example, the deeply held belief that accountants are ‘dull, dull, dull’, on coming across an exciting member of the profession, one who wanted to be a lion tamer perhaps, it is likely that we would come to the conclusion that, whilst there may be a subtype of accountants who have a fascinating personal life, our previously held notion, that they should not be one’s first choice for an interesting dinner party guest, would still seem to us a valid one. In contrast, where strong convictions are not held about a group of people, new information about such a group is more easily assimilated. So, for example, not knowing much about homicidal barbers, on encountering one who secretly desired to be a lumberjack, it would not be cognitively difficult to incorporate such longings as being typical of the group as a whole.
Making a diagnosis can be likened to the applying of a stereotype, but like stereotypes they too can be misapplied and difficult to change once one has it ones mind that the diagnosis we have settled on is right. So take breathlessness for example. When an individual known to have ischaemic heart disease presents with dyspnoea we may be too quick to jump to the conclusion that the individual has heart failure. Whilst there is of course some justification for this, as heart failure is indeed more common in people with IHD, one can perhaps see how, were the actual cause of the dyspnoea to be multiple PEs, we may find it difficult to be persuaded to change our mind and alter how we manage the individual in front of us.
And if we need to be careful about applying stereotypical diagnoses where there are diagnostic tests that give some objectivity to the diagnostic process, we need to be more careful still when no such objective diagnostic test exists. This was, I suspect, the thinking behind the aforementioned clinical psychologists comment, particularly in regard to the labelling and subsequent management of those experiencing emotional distress. Once given a psychiatric label in keeping with a biomedical understanding of their distress, there is evidence that suggests that such individuals are more likely to be medicated and do less well than those who are seen as individuals experiencing a collection of difficult emotions which are understandable as a response to the situation they find themselves in.
These days, the only label I allow myself to give such patients is their name because, rather than asking somebody what’s ‘wrong’ with them, surely it’s better to ask them what’s been going on that has made them feel the way they do.
Finally, I wonder about the effect of the labels that we give ourselves. Do we sometimes see ourselves in unhelpfully stereotypical ways. This week I came across this quote by Jonathan Landry Cruse:
‘The hunt for an identity is the hunt for something that is true of me in every circumstance I’m in. But we are changing beings; our desires our constantly in flux. If we base our identity in transient things we’ll be constantly disoriented, lost and unfulfilled’
Not infrequently I hear of those who are completely devastated having experiencing the unpleasantness of being complained about or as a result of making a significant mistake. I understand the feeling having been there myself but, I wonder, might it be that we are shaken to the degree we have formed unhelpful stereotypes of who exactly we are. Our mistakes are highly salient to us, of course they are, but we must be careful not to make illusory correlations whereby, as a result of such ‘transient things’ we stereotype ourselves as medical failures. The likelihood of our doing so is, I suspect, increased if, as is perhaps true of many of us, we already have a nagging doubt that we aren’t good enough and that everyone else is so much better than we are. Once the stereotype is established, it then becomes increasingly difficult for us to see ourselves as anything other than a failure and any good thing we might do is explained away as an aberrant exception to our fundamental nature, a subtype of our behaviour that doesn’t change the principal truth of our inadequacy.
We need to treat ourselves like we ought to treat our patients, as complex individuals who are more complicated than the simplistic diagnostic label that we too often inappropriately apply to them. We need to understand that we, like them, are affected by our circumstances and that we are indeed ‘changing beings’ who are ‘constantly in flux’. We must not base our, or our patients identity, on transient things such as the isolated mistakes that we all make.
On the contrary, when such things occur we need to know that we’re not alone, that we are not atypical of the profession. Most of us will have had serious complaints made against us, those who haven’t almost certainly will in time and, despite the fact that many of these will be unfounded, we will do well to seek advice from the medical defence organisations which exist precisely because all doctors sometimes make mistakes.
Though it may take a long time for complaints to be resolved, we need to try to remember that neither we nor our careers are defined by an individual case. Sometimes I think our job is a bit like pushing people out of the way of speeding trains. Sometimes we will fail to push someone away in time. Sometimes we might get hit ourselves. During our working life we’ll be involved in thousands and thousands of cases where our management has been sound and disaster has been averted. We need to try to remember all the good we have done, all the people we have helped, all those bad outcomes we have played a part in preventing.
Hopefully, when we are the subject of a complaint, we will eventually be shown not to be at any fault but, inevitably, this won’t always be the case. But even then, any mistake we may have made will have been an honest one. We all sometimes do things wrong, for a variety of reasons – sometimes simply as a consequence of our all being human and, therefore, far from perfect. Being a GP is a hugely demanding career, medicine a hugely complex subject, we all, therefore, will sometimes get it wrong. And so, on those occasions we are deemed to be at fault, though we will appropriately feel regret and should endeavour to apologise to those we have harmed, we also need to try not to be too hard on ourselves. The going though will not be easy and we will need the support of colleagues we trust – we shouldn’t be afraid to ask for and accept their help. More importantly still we will need to keep those we love and who love us close, knowing that our relationships with them are unchanged since, I trust, they were never based on our having to be perfect in the first place. We are loved because there are those who love us. We need to be humble enough to take some comfort from the fact that really being loved, loved even when our mistakes are up front and central, says more about the qualities of the one who loves than the one who is loved. Rather than insisting on being somebody who is perfect and is always there to give, we will do well to joyfully experience being somebody who is imperfect but continues to receive the unconditional love necessary to cover our mistakes.
Rather than pretending to be the perfect clinicians we are expected to be, we need, as a profession, to acknowledge our need to be supported in our genuine weakness.
To know oneself to be always loved, always accepted, is perhaps what we need to avoid being ‘constantly disorientated, lost and unfulfilled’. If we are fortunate enough to experience this in our lives, then we may find ourselves better able to continue, even whilst being the subject of a complaint, to care for our patients as well as we always have, the way we stereotypically do.
We are more than just our mistakes. We are more, even, than simply doctors. And seeing ourselves as such will increase the chance of our treating those who come to us, not as merely patients in need of a diagnostic label, but rather as people just like us.
GPs do indeed need a lot more guidance on how NOT to diagnose people. So, by way of a start, rather than telling me what you call yourself, tell me your name. Because it’s not what you are, but who you are, that matters.
Some musings 