Minimalist Medicine & Diagnosing Normality

Our intern gave a really good summary at a clinical meeting this week about an article entitled “Diagnostic Inflation” by Dr. Laura Bastra, PhD and Dr. Allen Frances, MD (1).  He gave his talk the title, “When normal is not normal anymore”.  He raised concerns about how the American Psychiatric Association’s new Diagnostic and Statistical Manual of Mental Disorders, version 5 (DSM-V) has included what some may consider to be fairly vague diagnoses of human conditions within the realm of normal.  A classic example raised today was ‘temper dysregulation disorder with dysphoria’ – is this a new excuse for those with short tempers?  I wonder what temper dysregulation disorder with euphoria would look like?  In recent months there was also a lot of controversy around the removal in the DSM-V of the bereavement exemption from the diagnostic criteria for major depression, which many have viewed as having the potential for pathologising the normal human grief response.

The article itself looked at the issues associated with over-diagnosis and the over-medicalisation of normality.  The authors advised a “Stepped Diagnosis” approach for psychological complaints, with watchful waiting and minimal interventions advised before labeling someone with a potentially stigmatizing mental health condition.  It encouraged normalising problems (without minimising their gravity), which I think that thankfully, most of us try to do in our everyday general practice already.

These discussions around over-medicalisation reminded me of the frequent consultations I have with parents and young children where I am providing reassurance, explanations and education about normal developmental stages of life.  One bugbear of mine is the term ‘colic’, which means a multitude of different things to different people.  I am so grateful for the “Period of Purple Crying” website, which focuses on normalising the period of irritability and excessive crying in an infant’s early life and encourages avoidance of the term “colic”, which implies that there is some pathological process occurring, which is most commonly not the case at all.

The similar theme of a ‘do nothing’ approach was touched upon in a recent article in Australian Family Physician (2), as referenced on Twitter:

Screen Shot 2013-07-11 at 6.53.50 PM

There was another tweet only the day before referencing an article from the British Medical Journal (3) along the same lines:

I agree with what Des writes in his article, that “medicine is about comfort and reassurance.”  After all, doing nothing aligns rather well with the Hippocratic principle of primum non nocere (first do no harm), which my medical class recited from the Declaration of Geneva at our graduation.

I always thought there was merit in this approach, and this was re-iterated when I read the “bawdy cult classic” novel, “The House of God” (4), and the medical intern protagonist Dr. Roy Basch learns from his senior resident, The Fat Man, the laws of the House of God.  He follows The Fat Man’s advice and does nothing to the gomers (patients), and they actually remain in good health.  Truth is often stranger than fiction, and I have seen examples of this many times when active treatments are withdrawn from palliative patients nearing the end of life, followed by their miraculous improvement!

However, I believe that there is a difference between ‘doing nothing’ and providing reassurance with watchful waiting.  There is a difference between normalising symptoms with vindication about the way that a patient feels, and standing idly by doing nothing.  Reassurance and an actively listening ear from a general practitioner are hugely powerful.  Arranging appropriate follow up, unless the patient is cynical and assumes you are trying to drum up business, can also be very reassuring to an anxious patient.  A lot of the resistance to normalising symptoms in the general practice world, I believe, stems from a need to ‘do something’ and an uncomfortable feeling if there is some uncertainty in a diagnosis.  Sometimes we doctors institute treatments because we feel this need to ‘do something’, or we give in to patient pressure for a quick-fix medication, which is often an attempt to treat our own anxieties, rather than a legitimate illness in the patient.  But at what cost?  No medication or herbal remedy comes without potential side effects.  With appropriate reassurance, education and explanation, I find that most patients are willing to accept ‘no treatment’ as a good treatment.

References:

1. Batstra, L and Frances, A.  Diagnostic Inflation, Causes and a Suggested cure.  The Journal of Nervous and Mental Disease, Volume 200, Number 6, June 2012.

2. Cooke, G and Mitchell, B.  A is for aphorism ‘Nothing is sometimes a good remedy’, Australian Family Physician, Volume 42, No.7, July 2013 Pages 507-508

3. Spence, D.  The power of doing nothing, BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f4409 (Published 9 July 2013); Cite this as: BMJ 2013;347:f4409

4. Shem, S.  The House of God.  The Bodly Head Ltd.  Great Britain.  1979.

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9 thoughts on “Minimalist Medicine & Diagnosing Normality

  1. Great post Mel.

    Rule 13 of the House of God you refer to is one of the best:
    THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE

    I have enjoyed observing my change in practice working closer to specialists this year. When my ReCEnT data comes back, Im sure it will show a rise in my referrals. Ah, to be back in the country and deal with more of the problems (and reassure) myself.

  2. Great post, Mel! I totally agree with you that there is definitely an art to doing nothing. The patients perception of their care totally changes with good explanation, reassurance, follow-up and empathy compared with dismissiveness. Your patients are very lucky to have you.

  3. Thanks Mel

    ‘Reassurance and an actively listening ear from a general practitioner are hugely powerful’

    You would really enjoy Hippocrates Shadow – Newman in particular the sections relating to the meaning response.
    Regarding ‘normal not being normal’ I love telling parents who are keen for a paed referral that the polite and attentive child playing with toys doesn’t have ADHD or Aspergers. Particularly now the latter is gone from the DSM….

    Warmly
    Daryl

  4. Docere – to teach

    We are teachers first and foremost. And in the absence of the ubiquitous grandmother or ‘wise woman’ in modern families, doctors are increasingly having to reassure people that what they experience is normal, not needing intervention.

    Sadly the fear of litigation drives much prescribing, investigation or referral ‘just in case’. I am grateful to theNNT.com for allowing me to treat the patient, not the disease (have a look at NNT for primary prevention of IHD with statins for example)

    As rime goes on, my approach to many conditions devolves to ‘do nothing for two weeks’ (trauma, MI and other major presentations excepted!)

    So – dont just do something – stand there!

  5. I agree. I often tell my trainees that “Sometimes an inaction is an action”. If an inaction is due to inertia or procrastination, then you might to change that as it might not be the most appropriate “action”.

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