Have you ever gone to the doctor because you were concerned about certain symptoms you were having and yet after listening to your symptoms, giving you a physical and running tests the doctor’s response was “You’re fine, there’s nothing wrong with you”? If so, you’re not alone. We’ve heard stories like this from many patients over the years.
If your doctor was particularly rude and unsympathetic, they might have said something like “it’s all in your head”. If your doctor was more compassionate and understanding they might have said “I’m sorry but I can’t find anything wrong with you”. This experience will leave some people confused and wondering if they are making it all up. It will leave others angry and distrustful of their doctor or the medical system in general. Either way, the patient is left without help for what is ailing them and the dismissal by a medical professional only adds insult to injury.
Part of this insult comes from the tendency to label conditions that do not fit into accepted conventional diagnoses as being “psychological” and applying labels such as psychosomatic, hypochondriac, somatiform disorder, conversion disorder or malingerer to the patient and their condition. Patients are often then sent home without help, referred to psychiatrists or offered antidepressants.
Falling through the cracks
I refer to this as “falling through the cracks of the medical system”. And, while it seems to occur most often in conventional medical settings, it can happen with alternative medical practitioners as well.
In my view the problem starts with the way that doctors are taught to diagnose and understand disease. Medical students are taught pathology and diagnosis as a series of discreet medical conditions: Strep pharyngitis, gallstones or psoriasis for instance. Each of these conditions is taught with a corresponding set of symptoms, physical exam findings, imaging study findings and laboratory test results that help the practitioner to identify the condition.
In the clinic, doctors are looking for patterns of symptoms, lab results, etc. that match what they have been taught in school and continuing education programs. If there is no recognizable pattern of findings, and particularly if there are no laboratory or imaging findings (X-Ray, MRI, EKG, etc.) a diagnosis cannot be made. Often, how a patient feels is not sufficient for the doctor. In the absence of a medical diagnosis patients’ symptoms are often discounted or concluded to be “psychological” in nature.
Rather than the doctor saying “I don’t know what’s wrong with you” they say “There is nothing wrong with you” or somehow imply that your physical symptoms are really just manifestations of a psychological problem.
For years irritable bowel syndrome and fibromyalgia were dismissed in this way. They are now recognized as legitimate health conditions within the conventional medical community. Consider the tens of thousands of patients (most of them women) who were told “it’s all in your head” prior to the official acceptance of these conditions.
In essence, this approach says “until a health condition is officially recognized, it simply doesn’t exist”. Hmmm . . . . doesn’t seem very logical to me. It also leaves people without the help they are seeking and in a certain sense blames them for being the cause of their own suffering. Ouch!!!
To be fair . . .
There are good reasons why doctors are taught to diagnose in the way that they are. For starters, it actually works well for many conditions, such as Strep pharyngitis, gallstones and psoriasis. It works well for observable, discreet diseases that have consistent symptoms and produce consistent findings on lab tests and imaging studies.
But . . .
It doesn’t work well for many complex maladies that have varied symptom manifestations and often do not show consistent laboratory findings or imaging results. It also doesn’t respect the great deal of individuality and variability that exists from patient to patient.
The way that conventional medicine is practiced is becoming more and more standardized, predetermined and automatized. It is actually an attempt to improve the quality of care, which is a worthy goal. The problem is that people are not standard. People are unique individuals and no two patients are the same, and so a certain number of people simply fall through the cracks because they don’t fit into the accepted diagnostic categories. Sadly, rather than acknowledge the limitations of the system, the system marginalizes patients who don’t fit the mold.
Following are some specifics on how our current system of diagnosis and assessment often fall short and leave patients without proper assessment and treatment.
Let’s plant the flagpole here!
Let’s start with lab tests. While they are certainly valuable tools in the assessment of health and illness, they are far from perfect and placing too much emphasis on them can often lead to missed or incorrect diagnoses. This is due in part to the limited usefulness of the “normal ranges” of many lab tests.
The normal ranges of many common lab tests are not determined by careful assessment of what values are correlated with health, but by performing a simple mathematical equation. To determine the normal ranges of many lab tests a large number of volunteers are given the test, their results averaged and then a statistical calculation made that places 5% of people outside the normal range on the high end and another 5% outside the normal range on the low end.
This shows that the medical community really doesn’t know where health stops and illness starts with regard to many lab values. It is just finding a convenient cut off point. This creates problems with diagnosis because these “normal ranges” are treated as if they do accurately identify health and disease and patients are treated, or not treated accordingly.
Furthermore, lab tests that might be helpful frequently aren’t run, most often due to the standardization of medical practice or due to the dictates of insurance companies who decide which tests they will or will not cover.
In addition, the criteria used to define health conditions themselves can also be somewhat arbitrary. For instance, there is a blood test used to diagnose diabetes that gives an average reading of a patient’s blood sugar for the last three months. It’s called the Hemoglobin A1c test. For years a Hemoglobin A1c of 6.0 was diagnostic for diabetes. A few years ago the value was changed to 6.4. So if your A1c value was 6.2 on the day the change was made, you went from being diabetic to being non diabetic overnight!
Similarly, the diagnostic criteria for fibromyalgia recently changed fairly dramatically so that many people who were not diagnosed previously because they did not meet the criteria now fit into the parameters for diagnosis. Suddenly we have many more people with fibromyalgia in our country!
The criteria used to diagnose illness define if and what type of treatment will be given because insurance companies pay for treatment based on the diagnosis and doctors tailor their treatment based on what they know insurance companies will pay for.
Climbing back out of the cracks
We see many patients who have been feeling unwell for years and been to a number of medical practitioners who told them “there’s nothing wrong with you”. Often, these patients are frustrated and emotionally exhausted by the time they come to our clinic.
Luckily, we use different criteria to assess the health of our patients. As one of my teachers in naturopathic medical school said “I’m a naturopath, I don’t need a diagnosis”. What we do need is the willingness to listen to what patients are telling us, a good understanding of physiology and biochemistry and an inquiring mind to search out the causes underlying their symptoms. In the vast majority of cases, this can be done with or without a formal diagnosis and treatment can be initiated. In fact, in many cases a diagnosis is not actually very helpful in understanding the underlying causes of a patient’s symptoms.
Under diagnosed and under treated
There are many reasons why real health conditions are often missed in conventional diagnosis. Here are a few that we see frequently in our clinic.
- Functional hypothyroidism: diagnosis of low thyroid function is generally done by running a single lab test, TSH, which is known to be highly inaccurate. In fact, some labs place a statement to this effect next to the lab results. But, if the test result comes back “normal” most physicians won’t look any further regardless of how well the patient’s symptoms match hypothyroidism (fatigue, difficulty losing weight, constipation, sensitivity to cold temperatures, depression, etc.).
- Adrenal fatigue: the adrenal glands produce hormones that help us respond to stress and levels of these hormones can become compromised after intense or prolonged periods of stress. This can lead to fatigue, emotional lability (very easily ticked off or tearful), anxiety, foggy thinking, low blood pressure and insomnia, all of which are very common symptoms. Although codes exist for this condition in the standard diagnostic manuals, it is not really acknowledged as a real condition and is rarely tested for. (On the rare occasion when it is tested for it is often missed because the conventional tests used to diagnose it are not reliable).
- Food intolerances: there are many ways in which the body can react adversely to foods that will not be caught by a standard allergy panel. The number of health conditions and symptoms that can be affected by problematic foods is far too great to list here, but symptoms can include fatigue, pain, brain fog, migraines, anxiety, constipation, diarrhea, weight gain, insomnia and many more. Conventional medical practitioners rarely consider food as a possible cause of illness.
Couldn’t it really just be in my head?
Psychological distress, a history of trauma or even certain stress producing beliefs and attitudes can certainly contribute to the emergence of symptoms. The idea that physical symptoms “are all in you head”, however, suggests that you made up your symptoms, that they are not really physical but only imagined. This is discounting, dismissive and false.
The brain is the single greatest regulator of physiological processes within the body. The part of the brain that deals with emotions and stress has strong connections to the parts of the brain responsible for regulation of physical functioning. Over time, emotional distress leads to physical imbalances, almost without exception. So yes, stress does cause physical symptoms, but those symptoms are just as real and just as much in need of treatment as if they were caused by a virus or bacteria.
Conversely, imbalances in certain organs or endocrine glands can have effects on one’s psychological or emotional state. Ask any woman with premenstrual syndrome or anyone with severe hypoglycemia (low blood sugar) or acute liver inflammation. So we could say that for some patients with psychological or emotional symptoms that “it’s all in your body”!
Modern medicine has long denied or minimized the connection between mind and body, although every form of traditional and indigenous medicine on the planet not only acknowledges the connection but sees the the mind and body as a unified whole and treats patients as such.
With chronic illness, it’s rarely “all in your body” or “all in your head” but both mind and body influencing each other.
I ‘m pretty sure we’d be healthier and happier as a culture if we let go of the idea that feeling lousy is somehow “normal”.
Anxiety, fatigue, pain, difficulty sleeping, abdominal discomfort and all other signs of dis-ease and distress are signs that something is out of balance, pure and simple. Paying close attention and trusting your instincts can help you sort out what it is and what needs to be done about it. Working with a trusted health care professional who takes your concerns seriously and works with you to resolve them can also be valuable and is sometimes important.
What’s your story?
If you have a story related to this topic that you would like to share I would like to hear about it and I’m sure others would benefit from it as well. It can sometimes be difficult to trust ourselves in the face of an expert telling us that we are wrong and hearing others’ experiences can be helpful. (You can enter your story into the “Comments” box below). Thanks.