I think what you outlined here does represent a necessary transition for trainees. You need to first be able to observe and describe. Only then can you move on to trying to “explain”.
But I agree that any provisional Dx and DDx needs to ultimately explain what it is that you’re observing.
And nice point about “I don’t know”. I’d be suspicious of any doc who has the answer for everything (or thinks they do).
Typically, a suffering patient would like to feel better and know he is going to be alright to live his life how he had lived in before he got sick or close enough to it. To live a meaningful for him life.
It is a disservice to your patients to teach them to seek truth. This is not the role and practice of a sane physician.
Disease in the philosophy of medicine is a concept different from illness. Perhaps reading up on the subject of your essay before writing let alone teaching would be helpful.
Seeking of truth is a matter of religion. Practice of medicine is to alleviate suffering of a patient who came to us to complain about something that is intolerable for him. Something that crosses the threshold of suffering that people can deal with in a community.
This is a superb article. Congratulations. As a former medical subspecialty educator, I am reminded of Osler's admonition about a diagnosis. You must first think of it. All subsequent events proceed from the diagnosis. What is the diagnosis? Without which you may have nothing, aside from a collection of lab studies, imaging and symptoms.
As a nurse and an educator, I have discovered that many providers (doctors, nurses, etc.) consider "evidence" nothing more than hospital protocols, practice bundles, and pharmaceutical pamphlets. The other day, I asked my students for the rationale behind some of the PPE used in standard precautions. The answer: It is hospital protocol, so we assume that they know what they are doing. Being me, I pressed them and asked whether they had read any research supporting the protocols. Deer in the headlights looks all around.
I tell my students, ad nauseam, to question everything through the lens of: Are we really accomplishing what we think we are, and is there a better way?
I love the question but disagree with some of your assertions. One in particular:
"...what could possibly be collected in the real world to inform one that such an explanation is right or wrong?" Someone with a completely different epistemology could see all manner of things or experience all manner of sensations that could support a belief. Your question begs another question: What is the real world? I share what I think is your belief that real is what we can understand via the scientific method. But there are phenomena that it does not capture. (For example what can the scientific method say about dreams, or the feeling of love?)
The experience of a patient who suffers is vastly different from a physician who practices medicine. This alone presupposes vastly different experiences of something called “disease”. Most diagnoses are not diseases but rather symptoms or syndromes since they do not have causes, which a disease out to have to be qualify for a concept of disease in medical philosophy.
There is no shared realty since most physicians operate with ready made facts and practices that they copy. They don’t necessarily understand why they are doing what they do or how this or that fact came into being. Practice of medicine today is memetic, collective by consensus, often impersonal, algorithmic, and manipulated from behind the scenes by administrators to adjust practice guidelines in response to regulatory and budget/insurance considerations.
There are vast differences between how physicians practice between generations within one location and within one generation between various areas of practice and/or geographic location. Even when having studied within the same school called “Western medicine”, how people who come from different cultures make sense of it and relate it to peculiarities of local people varies tremendously.
Further, when anyone mentions a term, various disciplines understand its meaning differently through the practices they were taught for manipulation of both the term and/or a patient.
What COVID-19 may teach us about interdisciplinarity.
Suffering is real but can be hard to collect objective evidence for. That is true.
I’m a philosophical materialist, at least as far as practical matters like doing medicine is concerned. I am strongly oppositional to a Postmodern assertion that there is more than a single shared objective Reality and therefore everyone gets to have her own truth.
Thanks for the response Erica. I don't disagree philosophically that there is a single shared objective reality. We may disagree on my belief that we do not know much about it. I choose to adapt a humble agnostic stance towards unexplained phenomena - which is a big bucket.
"Psychiatric diagnoses are descriptive in nature, but the lay public commonly misconceives them as causal explanations. [...]
Leading professional medical and psychiatric organizations commonly confound depression, a descriptive diagnostic label, with a causal explanation on their most prominently accessed informational websites. We argue that the scientifically inaccurate causal language in depictions of psychiatric diagnoses is potentially harmful because it leads the public to misunderstand the nature of mental health problems. Mental health authorities providing psychoeducation should clearly state that psychiatric diagnoses are purely descriptive to avoid misleading the public."
This paper is about depression, but it also holds for gender dysphoria, ADHD...
One example of how this can cause problems was discussed in the NYT almost a year ago, about ADHD:
Another is when a mental health practitioner provides a gender dysphoria diagnosis and refers to a physician for medical treatment--the physician might not realize the diagnosis does not have the same causal implication as those Dr. Li describes above.
Interested to hear if I misunderstood this. Thanks!
In Why We Get Sick, a book on Evolutionary Medicine, the authors indeed make your point. Psychiatric diagnoses are not explanatory. Evolutionists are obsessed w explanations. More ultimate the better. If we applied psychiatry standards to body medicine, the authors say that we will have to make such diagnosis as cough disorder. Imagine we devised treatment based on that.
I don’t have a solution for this. I assume the mind is too complex for there to be clear explanatory hypotheses fashioned for symptoms. Even if we can, fashioning treatments around ultimate psychiatric explanatory hypotheses may be impractical.
I'm not a health care professional, but I do have a scientific background, and my question is: what about those psychiatric diagnoses that can be causally linked to disorders of the brain, such as strokes, tumors, various degenerative processes, etc., that increasingly can be detected via scans or other methods? It seems that advances in neuroscience may yet identify the physical origins of many maladies that are now just vague collections of symptoms.
I'll offer a different angle that is relevant to us all: When is a diagnosis not a disease? Alternatively, are diagnoses always 'diseases'. For example, One may argue that red hair is a diagnosis, but it surely is not a disease. Constitutional short stature is not a disease but some parents may demand treatment. How about Gilbert syndrome (mild hyperbilirubinemia)? --a lab finding with no clinical relevance to the affected individual, though an ill-informed clinician may decide to 'work it up', which itself may be cause harm. At one time homosexuality was a disease, and then by fiat it wasn't. The American College of Cardiology's can double the population of hypertensives by stroke of pen by redefining hypertension. Drug manufacturers won't rest until every one of us carries a diagnosis of hypercholesterolemia and is taking their pills.
How about a positive covid test in an otherwise asymptomatic individual? In many jurisdictions, these souls had serious limits on their civi liberties based on the evidence-free assertion that they 'might' spread covid. And contrary to evidence, public health authorities considered vaccinated individuals as if they wore a magic cape that prevented the spread of covid. Compare this to the 30 percent of the general public who walk around with staph aureus in their noses. Like those with a positive covid test they 'might' spread staph infection to another, right? Outside of high school wrestlers, this risk is extremely low and not worth our concern. Common sense reigns, and we don't treat staph carriers as infected pariahs.
The point of the above examples, among many more, is the influence of sociology on medicine. The sociocultural norms of society subject medicine to massive biases that easily result in net harm.
I always thought that the old medical CPC challenge of the revered expert making the diagnosis was antiquated and silly. But the challenge of "making the diagnosis" seems to be carried to the extreme in these days of coding correctly to get the maximum payment.
I have had my diagnostic coups. During my internship in 1964 I worked up a patient on the woman's ward who explained to me about how she one by one gained weight, started to get increased blood sugar, then blood pressure, then some increased hair on her lip, stretch marks on her abdomen and bruises on her arms. My sole diagnosis on my handwritten H&P was Cushing's Syndrome and wouldn't you know she turned out to have a pituitary tumor. My resident and attending were flabbergasted.
I also recall in my practice a long-time patient who on one of her visits sat across from my desk and kept pushing up her eyelids with her finger. She was getting myasthenia gravis and I guessed it, the only time I ever saw it. I was quite proud of myself, although there was no resident to impress that time.
But by and large I never viewed what I did for my patients to be making a diagnosis and applying the corresponding treatment. My view is that medical practice is a service relationship that starts with an individual with a unique medical concern. Each one of us has attained a certain body of medical knowledge and what we do is to take that knowledge base, modified by our experience and personal human skills, and we use the resources available to us and our colleagues in our community and apply it to the problem of that individual person sitting in front of us who comes to us seeking help and advice.
When I was still in practice and dutifully coded my bills for the third-party payors I always used a single broad multipurpose diagnosis. These days as I understand it that doesn't fly if you want to make the best income. Too bad. We should be paid by how well we satisfy the patient.
Terrific observations! A good history often gives you the diagnosis. Young child in ED for minor trauma; diagnosed porphyria that had been overlooked during several recent pediatrics admissions for n/v and seizures.
Great article. I would add that there is still a lot we don't understand about the human body. Today's recommendations may not be tomorrow's. It is important for doctors to stay up to date on the latest research as well as keep an open mind that the latest research may totally upend the status quo. I have read that, on average, it takes 20 years for the medical community to adopt new research. The first one that came to mind was the doctor that proved H. Pylori caused ulcers - he was laughed out of the room at the conference where he presented his findings.
I in fact had H. Pylori and symptomatic for 6 years including a bleeding ulcer at age 8. Lack of diagnosis led to non resolution of symptoms. Getting the diagnosis right and treating w combo antibiotics cured me. Barry Marshall is a hero!
Same response today when anyone questions whether our cholesterol hypothesis is wrong. I believe it is, and it’s not a stretch to say that the root problem is inflammation. Some on a ketogenic diet have very high TC and LDL, yet no evidence of ASCVD.
... Ironic, but a recent article here on substack pretty much debunked the "H. Pylori causes ulcers" stunt as bad science that failed to meet any reasonable standard of evidence. He didn't "prove" it. It is, in fact, very unlikely to be true.
See above. My lived experience fortunately jives with scientific evidence!
The reductive evidence of proving disease causation may never be fulfilled because H. Pylori cannot grow in non human experimental subjects and obviously infecting healthy human subjects is unethical. It would be foolish to not treat patients because of an impossibility of doing causal experiments.
The empirical evidence of curing large populations w peptic ulcer with combination antibiotics which kills H pylori in vitro is sufficient.
Thanks for the link. I never accepted the H. Pylori theory because it just didn't make any sense. It is nice to know that the "evidence" is so thin-- actually nonexistent.
Very interesting. Thank you for sharing that. Still, my point remains unchanged, and maybe the example still proves the point that it is important to remain open-minded. I would add now that remaining cautious and careful about reviewing data is also important.
No it is a word. What matters is the connection that the word implies.”
Many doctors think a diagnosis must be a fact. It is not. It is an opinion. The two things may be the same but they also may not. And given that facts are also negotiable the foundation become even more shaky.
Great essay, thank you ! I have a student starting with me next week for a 6 week family medicine core rotation. This is a great way to ground the learner with proper orientation.
Great post.
I think what you outlined here does represent a necessary transition for trainees. You need to first be able to observe and describe. Only then can you move on to trying to “explain”.
But I agree that any provisional Dx and DDx needs to ultimately explain what it is that you’re observing.
And nice point about “I don’t know”. I’d be suspicious of any doc who has the answer for everything (or thinks they do).
Who experiences disease in reality?
All philosophers can vote.
https://x.com/medical_nemesis/status/2019475079445336130?s=46
Typically, a suffering patient would like to feel better and know he is going to be alright to live his life how he had lived in before he got sick or close enough to it. To live a meaningful for him life.
It is a disservice to your patients to teach them to seek truth. This is not the role and practice of a sane physician.
Why do we diagnose? https://substack.com/@medicalnemesis/note/c-210365002?utm_source=notes-share-action&r=fqn5o
What is the purpose of a physician?
https://substack.com/@medicalnemesis/note/c-210369539?utm_source=notes-share-action&r=fqn5o
It does a disservice to teach people to seek truth? Are you serious?
Great. Let’s go back to the hypothesis that disease was caused by witchcraft. Let us see how that resolves suffering.
Disease in the philosophy of medicine is a concept different from illness. Perhaps reading up on the subject of your essay before writing let alone teaching would be helpful.
Seeking of truth is a matter of religion. Practice of medicine is to alleviate suffering of a patient who came to us to complain about something that is intolerable for him. Something that crosses the threshold of suffering that people can deal with in a community.
Ok pomo pedant
https://x.com/medical_nemesis/status/2019475079445336130?s=46
This is a superb article. Congratulations. As a former medical subspecialty educator, I am reminded of Osler's admonition about a diagnosis. You must first think of it. All subsequent events proceed from the diagnosis. What is the diagnosis? Without which you may have nothing, aside from a collection of lab studies, imaging and symptoms.
And what a bane it is to read notes that consists merely of a collection of lab studies, imaging, and events that occurred without explanations!
Essentially do not pau attention to lab and imaging results in the Notes. Rather I go directly to the lab and imaging facilities on line.
Oh dude. Tell me about it.
As a nurse and an educator, I have discovered that many providers (doctors, nurses, etc.) consider "evidence" nothing more than hospital protocols, practice bundles, and pharmaceutical pamphlets. The other day, I asked my students for the rationale behind some of the PPE used in standard precautions. The answer: It is hospital protocol, so we assume that they know what they are doing. Being me, I pressed them and asked whether they had read any research supporting the protocols. Deer in the headlights looks all around.
The health professions tend not to attract mavericks by and large. Jay Bhattacharya, remember, was labeled as a “fringe” doctor.
I tell my students, ad nauseam, to question everything through the lens of: Are we really accomplishing what we think we are, and is there a better way?
I love the question but disagree with some of your assertions. One in particular:
"...what could possibly be collected in the real world to inform one that such an explanation is right or wrong?" Someone with a completely different epistemology could see all manner of things or experience all manner of sensations that could support a belief. Your question begs another question: What is the real world? I share what I think is your belief that real is what we can understand via the scientific method. But there are phenomena that it does not capture. (For example what can the scientific method say about dreams, or the feeling of love?)
No. I speak from the experience of practice.
The experience of a patient who suffers is vastly different from a physician who practices medicine. This alone presupposes vastly different experiences of something called “disease”. Most diagnoses are not diseases but rather symptoms or syndromes since they do not have causes, which a disease out to have to be qualify for a concept of disease in medical philosophy.
There is no shared realty since most physicians operate with ready made facts and practices that they copy. They don’t necessarily understand why they are doing what they do or how this or that fact came into being. Practice of medicine today is memetic, collective by consensus, often impersonal, algorithmic, and manipulated from behind the scenes by administrators to adjust practice guidelines in response to regulatory and budget/insurance considerations.
There are vast differences between how physicians practice between generations within one location and within one generation between various areas of practice and/or geographic location. Even when having studied within the same school called “Western medicine”, how people who come from different cultures make sense of it and relate it to peculiarities of local people varies tremendously.
Further, when anyone mentions a term, various disciplines understand its meaning differently through the practices they were taught for manipulation of both the term and/or a patient.
What COVID-19 may teach us about interdisciplinarity.
https://pubmed.ncbi.nlm.nih.gov/33328203/
S. Kay Toombs
The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient (Philosophy
and Medicine, 42).
Raymond Downing.
Suffering and Healing in America: An American Doctor's View
from Outside
This is a word semi-salad assuming supremacy of the lived experience.
Suffering is real but can be hard to collect objective evidence for. That is true.
I’m a philosophical materialist, at least as far as practical matters like doing medicine is concerned. I am strongly oppositional to a Postmodern assertion that there is more than a single shared objective Reality and therefore everyone gets to have her own truth.
Thanks for the response Erica. I don't disagree philosophically that there is a single shared objective reality. We may disagree on my belief that we do not know much about it. I choose to adapt a humble agnostic stance towards unexplained phenomena - which is a big bucket.
I agree! I think ultimately such attitude is scientific
I hope Dr. Li will also write about psychiatric diagnoses. In this case, I have read that **it is** often a collection of symptoms.
Quoting https://karger.com/psp/article/57/5/389/909052/A-Descriptive-Diagnosis-or-a-Causal-Explanation :
"Psychiatric diagnoses are descriptive in nature, but the lay public commonly misconceives them as causal explanations. [...]
Leading professional medical and psychiatric organizations commonly confound depression, a descriptive diagnostic label, with a causal explanation on their most prominently accessed informational websites. We argue that the scientifically inaccurate causal language in depictions of psychiatric diagnoses is potentially harmful because it leads the public to misunderstand the nature of mental health problems. Mental health authorities providing psychoeducation should clearly state that psychiatric diagnoses are purely descriptive to avoid misleading the public."
This paper is about depression, but it also holds for gender dysphoria, ADHD...
One example of how this can cause problems was discussed in the NYT almost a year ago, about ADHD:
https://www.nytimes.com/2025/04/13/magazine/adhd-medication-treatment-research.html
Another is when a mental health practitioner provides a gender dysphoria diagnosis and refers to a physician for medical treatment--the physician might not realize the diagnosis does not have the same causal implication as those Dr. Li describes above.
Interested to hear if I misunderstood this. Thanks!
In Why We Get Sick, a book on Evolutionary Medicine, the authors indeed make your point. Psychiatric diagnoses are not explanatory. Evolutionists are obsessed w explanations. More ultimate the better. If we applied psychiatry standards to body medicine, the authors say that we will have to make such diagnosis as cough disorder. Imagine we devised treatment based on that.
I don’t have a solution for this. I assume the mind is too complex for there to be clear explanatory hypotheses fashioned for symptoms. Even if we can, fashioning treatments around ultimate psychiatric explanatory hypotheses may be impractical.
I'm not a health care professional, but I do have a scientific background, and my question is: what about those psychiatric diagnoses that can be causally linked to disorders of the brain, such as strokes, tumors, various degenerative processes, etc., that increasingly can be detected via scans or other methods? It seems that advances in neuroscience may yet identify the physical origins of many maladies that are now just vague collections of symptoms.
Here’s a reflection on , among other things-diagnosis from quite a long time ago:
Life is short,
The art is long.
Evidence deceptive and
Diagnosis difficult.
Hippocrates
Such a good read. Something to save and go back to regularly.
Thank you!
Insightful essay.
I'll offer a different angle that is relevant to us all: When is a diagnosis not a disease? Alternatively, are diagnoses always 'diseases'. For example, One may argue that red hair is a diagnosis, but it surely is not a disease. Constitutional short stature is not a disease but some parents may demand treatment. How about Gilbert syndrome (mild hyperbilirubinemia)? --a lab finding with no clinical relevance to the affected individual, though an ill-informed clinician may decide to 'work it up', which itself may be cause harm. At one time homosexuality was a disease, and then by fiat it wasn't. The American College of Cardiology's can double the population of hypertensives by stroke of pen by redefining hypertension. Drug manufacturers won't rest until every one of us carries a diagnosis of hypercholesterolemia and is taking their pills.
How about a positive covid test in an otherwise asymptomatic individual? In many jurisdictions, these souls had serious limits on their civi liberties based on the evidence-free assertion that they 'might' spread covid. And contrary to evidence, public health authorities considered vaccinated individuals as if they wore a magic cape that prevented the spread of covid. Compare this to the 30 percent of the general public who walk around with staph aureus in their noses. Like those with a positive covid test they 'might' spread staph infection to another, right? Outside of high school wrestlers, this risk is extremely low and not worth our concern. Common sense reigns, and we don't treat staph carriers as infected pariahs.
The point of the above examples, among many more, is the influence of sociology on medicine. The sociocultural norms of society subject medicine to massive biases that easily result in net harm.
Good points!
I always thought that the old medical CPC challenge of the revered expert making the diagnosis was antiquated and silly. But the challenge of "making the diagnosis" seems to be carried to the extreme in these days of coding correctly to get the maximum payment.
I have had my diagnostic coups. During my internship in 1964 I worked up a patient on the woman's ward who explained to me about how she one by one gained weight, started to get increased blood sugar, then blood pressure, then some increased hair on her lip, stretch marks on her abdomen and bruises on her arms. My sole diagnosis on my handwritten H&P was Cushing's Syndrome and wouldn't you know she turned out to have a pituitary tumor. My resident and attending were flabbergasted.
I also recall in my practice a long-time patient who on one of her visits sat across from my desk and kept pushing up her eyelids with her finger. She was getting myasthenia gravis and I guessed it, the only time I ever saw it. I was quite proud of myself, although there was no resident to impress that time.
But by and large I never viewed what I did for my patients to be making a diagnosis and applying the corresponding treatment. My view is that medical practice is a service relationship that starts with an individual with a unique medical concern. Each one of us has attained a certain body of medical knowledge and what we do is to take that knowledge base, modified by our experience and personal human skills, and we use the resources available to us and our colleagues in our community and apply it to the problem of that individual person sitting in front of us who comes to us seeking help and advice.
When I was still in practice and dutifully coded my bills for the third-party payors I always used a single broad multipurpose diagnosis. These days as I understand it that doesn't fly if you want to make the best income. Too bad. We should be paid by how well we satisfy the patient.
Terrific observations! A good history often gives you the diagnosis. Young child in ED for minor trauma; diagnosed porphyria that had been overlooked during several recent pediatrics admissions for n/v and seizures.
Great read. Thanks for your time.
Great article. I would add that there is still a lot we don't understand about the human body. Today's recommendations may not be tomorrow's. It is important for doctors to stay up to date on the latest research as well as keep an open mind that the latest research may totally upend the status quo. I have read that, on average, it takes 20 years for the medical community to adopt new research. The first one that came to mind was the doctor that proved H. Pylori caused ulcers - he was laughed out of the room at the conference where he presented his findings.
True statement and little known fact.His correct observation predated everyone catching up by almost 20 years I believe.
I in fact had H. Pylori and symptomatic for 6 years including a bleeding ulcer at age 8. Lack of diagnosis led to non resolution of symptoms. Getting the diagnosis right and treating w combo antibiotics cured me. Barry Marshall is a hero!
Same response today when anyone questions whether our cholesterol hypothesis is wrong. I believe it is, and it’s not a stretch to say that the root problem is inflammation. Some on a ketogenic diet have very high TC and LDL, yet no evidence of ASCVD.
... Ironic, but a recent article here on substack pretty much debunked the "H. Pylori causes ulcers" stunt as bad science that failed to meet any reasonable standard of evidence. He didn't "prove" it. It is, in fact, very unlikely to be true.
Interesting. Do you still have the source? Patients treated for HP have documented resolution of their PUD. Not cause and effect?
See above. My lived experience fortunately jives with scientific evidence!
The reductive evidence of proving disease causation may never be fulfilled because H. Pylori cannot grow in non human experimental subjects and obviously infecting healthy human subjects is unethical. It would be foolish to not treat patients because of an impossibility of doing causal experiments.
The empirical evidence of curing large populations w peptic ulcer with combination antibiotics which kills H pylori in vitro is sufficient.
https://open.substack.com/pub/unbekoming/p/h-pylori-and-the-ulcer-myth
Thanks for the link. I never accepted the H. Pylori theory because it just didn't make any sense. It is nice to know that the "evidence" is so thin-- actually nonexistent.
Very interesting. Thank you for sharing that. Still, my point remains unchanged, and maybe the example still proves the point that it is important to remain open-minded. I would add now that remaining cautious and careful about reviewing data is also important.
To quote a great scene in an okay film…
“You have never heard a programme speak of love.
It’s is a human emotion.
No it is a word. What matters is the connection that the word implies.”
Many doctors think a diagnosis must be a fact. It is not. It is an opinion. The two things may be the same but they also may not. And given that facts are also negotiable the foundation become even more shaky.
Great essay, thank you ! I have a student starting with me next week for a 6 week family medicine core rotation. This is a great way to ground the learner with proper orientation.