Whose Diagnosis Is It?

Every parent and every patient mature enough to verbalize issues of cause and effect harbors an explanation for his or her symptoms. This may be one of the traits that defines us as humans and probably was a necessary ingredient for the birth of religion. Often, the patient’s explanation is naïve and unsophisticated. One might call it a proto-diagnosis.

However, as science and information technology have blossomed, an increasing number of parents and patients concoct elaborate and sophisticated explanations for what is ailing them before they arrive at our offices. Often the culprit is "something I ate." Sometimes it is an "allergy." The wise physician will always listen attentively because many parents’ and patients’ suspicions are surprisingly accurate. However, sadly the majority of parents and patients get the diagnosis wrong. This is fortunate for physicians because otherwise many of us would be made redundant.

Redirecting a parent’s off-target diagnosis is one of the primary tasks for primary care physicians. It’s when we get to show off our diagnostic artistry, and it’s fun. But it isn’t fun when a parent has talked to one too many well-meaning amateur diagnosticians or clicked on one too many websites. Their once naïve proto-diagnosis can become ossified into, "I know Jason has X diagnosis and needs Y and Z medications."

Cracking this concretized misdiagnosis can be a frustrating challenge for even the most patient and experienced physician. This is particularly true if the complaint is a symptom of a naturally occurring benign phenomenon requiring nothing more than watchful waiting.

Dismantling a solidly constructed but incorrect parent-crafted diagnosis can take time. Often unnecessary laboratory work and imaging studies may be required to get parents to a place in which they can accept an alternative explanation with an open mind. Sometimes the result is a confrontational encounter that ends with the parent seeking a second opinion that more closely matches their own.

On the other side of the spectrum is the patient or parent who begins the visit with, "I am sure there is nothing wrong with my son, but I just want you to reassure me." This refreshing degree of candor can be a much-needed oasis in the otherwise hectic day of a primary care physician. And it can reflect a hard-earned level of confidence in the physician’s diagnostic ability and style.

But there can be a catch. Because even the parent who claims that all he or she wants is reassurance also harbors a proto-diagnosis or fear that they may not be able to verbalize without some coaxing. The physician can’t adequately reassure unless he understands what the parent or patient is worried about. I have met a few parents who have been very helpful by telling me at our very first meeting, "I want you to know, Dr. Wilkoff, that my cousin died of leukemia, and I may ask you to order a blood test at visits where you may not think it’s necessary."

Unfortunately, finding the chinks in a parent’s armor of denial is not always easy. I find that as the decades have rolled on I ask more often, "What do you think is wrong with your child?" Or, "What are you worried he might have?" At least it gives me a vague idea of the target where I should be aiming my reassurance. If I’m lucky, the distance between their concerns and theories and my perception of reality is manageable.

The scenario becomes most difficult when the fears or proto-diagnoses belong to someone who hasn’t come to the visit. I don’t want to send the messenger home empty handed. Arming them with an ample supply of convincing arguments and explanations that can survive a 20-minute drive home, or even worse, the 6 hours until the other parent gets home for dinner, is a challenge. Unfortunately, despite my best efforts, the message may still come across as, "The doctor said there was nothing wrong."

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.

Every parent and every patient mature enough to verbalize issues of cause and effect harbors an explanation for his or her symptoms. This may be one of the traits that defines us as humans and probably was a necessary ingredient for the birth of religion. Often, the patient’s explanation is naïve and unsophisticated. One might call it a proto-diagnosis.

However, as science and information technology have blossomed, an increasing number of parents and patients concoct elaborate and sophisticated explanations for what is ailing them before they arrive at our offices. Often the culprit is "something I ate." Sometimes it is an "allergy." The wise physician will always listen attentively because many parents’ and patients’ suspicions are surprisingly accurate. However, sadly the majority of parents and patients get the diagnosis wrong. This is fortunate for physicians because otherwise many of us would be made redundant.

Redirecting a parent’s off-target diagnosis is one of the primary tasks for primary care physicians. It’s when we get to show off our diagnostic artistry, and it’s fun. But it isn’t fun when a parent has talked to one too many well-meaning amateur diagnosticians or clicked on one too many websites. Their once naïve proto-diagnosis can become ossified into, "I know Jason has X diagnosis and needs Y and Z medications."

Cracking this concretized misdiagnosis can be a frustrating challenge for even the most patient and experienced physician. This is particularly true if the complaint is a symptom of a naturally occurring benign phenomenon requiring nothing more than watchful waiting.

Dismantling a solidly constructed but incorrect parent-crafted diagnosis can take time. Often unnecessary laboratory work and imaging studies may be required to get parents to a place in which they can accept an alternative explanation with an open mind. Sometimes the result is a confrontational encounter that ends with the parent seeking a second opinion that more closely matches their own.

On the other side of the spectrum is the patient or parent who begins the visit with, "I am sure there is nothing wrong with my son, but I just want you to reassure me." This refreshing degree of candor can be a much-needed oasis in the otherwise hectic day of a primary care physician. And it can reflect a hard-earned level of confidence in the physician’s diagnostic ability and style.

But there can be a catch. Because even the parent who claims that all he or she wants is reassurance also harbors a proto-diagnosis or fear that they may not be able to verbalize without some coaxing. The physician can’t adequately reassure unless he understands what the parent or patient is worried about. I have met a few parents who have been very helpful by telling me at our very first meeting, "I want you to know, Dr. Wilkoff, that my cousin died of leukemia, and I may ask you to order a blood test at visits where you may not think it’s necessary."

Unfortunately, finding the chinks in a parent’s armor of denial is not always easy. I find that as the decades have rolled on I ask more often, "What do you think is wrong with your child?" Or, "What are you worried he might have?" At least it gives me a vague idea of the target where I should be aiming my reassurance. If I’m lucky, the distance between their concerns and theories and my perception of reality is manageable.

The scenario becomes most difficult when the fears or proto-diagnoses belong to someone who hasn’t come to the visit. I don’t want to send the messenger home empty handed. Arming them with an ample supply of convincing arguments and explanations that can survive a 20-minute drive home, or even worse, the 6 hours until the other parent gets home for dinner, is a challenge. Unfortunately, despite my best efforts, the message may still come across as, "The doctor said there was nothing wrong."

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.

Every parent and every patient mature enough to verbalize issues of cause and effect harbors an explanation for his or her symptoms. This may be one of the traits that defines us as humans and probably was a necessary ingredient for the birth of religion. Often, the patient’s explanation is naïve and unsophisticated. One might call it a proto-diagnosis.

However, as science and information technology have blossomed, an increasing number of parents and patients concoct elaborate and sophisticated explanations for what is ailing them before they arrive at our offices. Often the culprit is "something I ate." Sometimes it is an "allergy." The wise physician will always listen attentively because many parents’ and patients’ suspicions are surprisingly accurate. However, sadly the majority of parents and patients get the diagnosis wrong. This is fortunate for physicians because otherwise many of us would be made redundant.

Redirecting a parent’s off-target diagnosis is one of the primary tasks for primary care physicians. It’s when we get to show off our diagnostic artistry, and it’s fun. But it isn’t fun when a parent has talked to one too many well-meaning amateur diagnosticians or clicked on one too many websites. Their once naïve proto-diagnosis can become ossified into, "I know Jason has X diagnosis and needs Y and Z medications."

Cracking this concretized misdiagnosis can be a frustrating challenge for even the most patient and experienced physician. This is particularly true if the complaint is a symptom of a naturally occurring benign phenomenon requiring nothing more than watchful waiting.

Dismantling a solidly constructed but incorrect parent-crafted diagnosis can take time. Often unnecessary laboratory work and imaging studies may be required to get parents to a place in which they can accept an alternative explanation with an open mind. Sometimes the result is a confrontational encounter that ends with the parent seeking a second opinion that more closely matches their own.

On the other side of the spectrum is the patient or parent who begins the visit with, "I am sure there is nothing wrong with my son, but I just want you to reassure me." This refreshing degree of candor can be a much-needed oasis in the otherwise hectic day of a primary care physician. And it can reflect a hard-earned level of confidence in the physician’s diagnostic ability and style.

But there can be a catch. Because even the parent who claims that all he or she wants is reassurance also harbors a proto-diagnosis or fear that they may not be able to verbalize without some coaxing. The physician can’t adequately reassure unless he understands what the parent or patient is worried about. I have met a few parents who have been very helpful by telling me at our very first meeting, "I want you to know, Dr. Wilkoff, that my cousin died of leukemia, and I may ask you to order a blood test at visits where you may not think it’s necessary."

Unfortunately, finding the chinks in a parent’s armor of denial is not always easy. I find that as the decades have rolled on I ask more often, "What do you think is wrong with your child?" Or, "What are you worried he might have?" At least it gives me a vague idea of the target where I should be aiming my reassurance. If I’m lucky, the distance between their concerns and theories and my perception of reality is manageable.

The scenario becomes most difficult when the fears or proto-diagnoses belong to someone who hasn’t come to the visit. I don’t want to send the messenger home empty handed. Arming them with an ample supply of convincing arguments and explanations that can survive a 20-minute drive home, or even worse, the 6 hours until the other parent gets home for dinner, is a challenge. Unfortunately, despite my best efforts, the message may still come across as, "The doctor said there was nothing wrong."

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at [email protected]. This column, "Letters From Maine," appears regularly in Pediatric News, a publication of Elsevier.