I got the "I don't know what's wrong with you" from a doctor followed up with "you aren't dying" and "don't come back". No treatment might often be the right solution but in that case it just appeared she lacked knowledge and empathy.
Intriguing piece. I practiced for 34 years in Internal Medicine, Infectious Diseases, HIV and Critical Care and never gave thought to what a the definition of a diagnosis was. If asked, I probably would have said it was “getting to the right answer so an appropriate treatment can be given”, or something like that.
Early on, however, I saw that every answer I came up with only generated more questions which further enhanced my knowledge and my ability to employ it. Sometimes this led me down rabbit holes where I found something I wasn’t expecting. I often had to admit I didn’t know but I always made sure a coherent plan was in place. I believe that is what is important to patients.
Despite the encomiums I would receive on occasion, by people who are now either dead or too old to remember, what has stayed with me in the twilight of my years is the connections I made with my patients, whether in the HIV Hospice, an ICU conference room or the bedside of someone who was, or wasn’t, getting better. I don’t hear any of that when I speak to the younger hospitalists or specialists and it makes me suspect something has been lost.
Sensible Medicine gives me a chance to reflect on these things.
This is an outstanding commentary that goes far beyond the nosology of disease, and I congratulate you on it.
If I may digress for a moment, I would like to shift the focus from diagnosis of disease to diagnosis of suffering. There are so many ways to categorize and break down human illness, but I would like to give a special shout-out to one of my personal heroes, the late Eric J. Cassell.
Cassell reminded us that when we are ill we experience a disorder, which he described as everything going on within our physiology—altered function—whether or not the patient or physician is even aware of it. He distinguished this from sickness, which reflects how the patient experiences, interprets, and thinks about what is happening to them. These experiences impart meaning to the patient’s life. Finally, he described disease as the pathophysiologic process to which we as physicians attribute the patient’s disorder.
As he memorably stated: “A disorder is what the patient has; a diagnosis is what the physician gives him.” I have always found this to be a powerful and clarifying way to think about health and disease.
But even more important to me was Cassell’s constant reminder that no matter how we classify illness or label disease, the sickness a patient experiences occurs in the whole person, because whatever happens to one part of the person happens to the whole. As he wrote, “it could not be otherwise.”
My comments are merely meant to serve as a gentle reminder that regardless of how we break down diagnosis—regardless of the strength of evidence supporting a pathophysiologic process, and regardless of how rational and effective our therapies may be—there remains a humanistic dimension that sits at the very core of our profession.
I used to remind medical students that I was confident they were becoming skilled at eliciting and appraising a chief complaint of symptoms.
Then I would ask them: How good are you at eliciting a chief complaint of suffering?
I experience a ray of light in the all too often gloom of our teaching hospital:
I saw a young man last week. He was hospitalized due to a combination of bad disease (complications of diabetes etc) and bad choices that had nothing to do with the aneurysm that prompted the consult for me, a surgeon. He and his spouse were cranky for many legitimate reasons,l. After our conversation, stated they were glad to see me because I would “do something and have a plan”. When I responded to a question with “hmmm… I don’t know”, he got cranky again because “that is what the other doctors (nephrologists and hospitalists and cardiologists) keep saying to us”.
This seems more common to me than it was in the past!
There are stronger and weaker arguments in this post. Its weakest parts are the shallow historical argument. The author appeals to a rhetorical question to reduce premodern medicine to practice that forewent investigation and production of material evidence. That is simply not true. Anyone who has read a lot of ancient Greek and Renaissance medicine will recognize the lengths those practitioners went to produce material evidence of their theories. Some examples: They investigated urines and produced diagnostic guides of color wheels to correlate urine color with a humoral diagnosis (Siraisi: Medieval and Early Renaissance Medicine); they used a burn test to distinguish GI causes of hemoptysis from potential tuberculosis (Hippocrates Aphorisms 5.11); in phlebotomy they used measurements of extravasated blood volume and qualitative measurements of the character of the blood against the clinical presentation of the radial pulse to determine the limits of bloodletting (Celsus On Medicine 2.10); they investigated in minute detail the chemical character, shape, and quantity of bladder stones to argue about the composition of the stones and thus the humoral etiology of urinary sediment (Ellis: A History of Bladder Stone). The author also urges us to underscore the limitations of scientific knowledge in communicating to patients our epistemic uncertainty. It is a worthy point, but it is not a valid criterion to distinguish premodern and thus nonscientific medicine from our contemporary medical practice. Premodern medicine is filled with reflection on the limitations of their knowledge and the risk in making diagnoses: some famous texts include Hippocrates The Art of Medicine, Hippocrates Prognostic, Galen The Method of Healing, whose discussions remained influential for much subsequent medieval and Renaissance medicine. I appreciate the author's general point that we would do better to reflect in a philosophical way on the epistemic tools we use to recognize disease and treat patients, but looking closely at the historical record complicates the notion of distance we sometimes try to develop between our own practice and the past.
There’s a new field called philosophy of medicine, a branch of philosophy of science. Why don’t you invite a professional philosopher to write about these things? (See Jacob Stegenga about Gentle Medicine; also the journal https://philmed.pitt.edu/)
I think Philosophy of Medicine should be a first year med school course. No fluff though. Taught by a practicing MD who sees patients. Organized debates during class, everyone needs to participate and speak.
I fully agree with the first year course but to be “taught by a practicing MD” would be a high standard that should be first applied to all the professors and researchers without a clinical practice.
Your making some interesting points in the essay, although I have some objections. I can argue that “truth-seeking” (or pretending) without epistemic humility have contributed to the social polarization today.
I admire MD’s with philosophical reflections but what I tried to highlight is that philosophizing it’s not the same as being a professional philosopher (of science specialized in medicine). Those are experts in metaphysical (what is?) and epistemological (how do we know?) problems. It’s not just conceptual thinking, they work with real problems and sometimes together with researchers and clinicians.
Curiously the American Society for Plastic Surgeons and the AMA came out with some hum-dinger statements today without any change in the evidence (or lack thereof from all along).
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.
Your students are correct. No hospital personnel come to work to critically think how this or that practice or fact emerged. Everyone operates with ready made knowledge — facts and practices. What you encourage them to do is to memorize facts that justify use of standard PPE. Yet you yourself never questions the facts as explanations.
Most in-hospital aka nosocomial infections are self-generated within patients themselves. A patient exhibits symptoms due to some imbalance and his own microflora becomes a conditional “cause” of symptoms that we then counter in a multitude of ways. We essentially decolonize a patient.
How does the use of PPE protect you from your own microflora?
How fast does a person get colonized with environmental flora in a hospital?
Why do patients get infected and visitors and personnel does not?
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.
Yes, I think psychiatry is just not there yet. Also, some conditions may be more amenable to change. For most conditions I believe it's at an earlier stage of understanding. More at the "cough diagnosis" stage.
But right now a huge issue is patients assuming an explanatory model always underpins a psychiatric diagnosis. Or medical colleagues believing this. In gender dysphoria this has led to treatment model which assumes a single cause, with the treatment being affirm the young person as they wish. See the AAP 2018 and renewed in its 2023 policy statement led by Rafferty.
The entire treatment pathway for which they advocate, from social transition to surgeries, does not have reliable outcome data.
Long term is particularly important because the surgeries and many of the drug effects are lifelong, including expected sterility for men who start taking the estrogen regimen at any age.
Although MDs talk about assessments, always a good idea, these can flag severe accompanying comorbid issues which may be relevant, but being prescribed medical intervention after being assessed does not mean there is any understanding of whether you are more likely to be harmed or helped by the interventions. One of the clinicians who started the first us pediatric clinic in 2007 said recently that if a young person goes to a gender clinic wanting hormones, they will get a referral for them.
A physician being given the green light to provide puberty blockers, anti androgens, testosterone, estrogen, surgeries may not understand this. The responsibility will include them, though. The asps mentions this responsibility in its excellent statement.
The no debate atmosphere around this condition has led to doctors and patients both thinking this subfield, with it's diagnosis and treatments, is on completely different footing regarding evidence than it actually is.
I quite agree that a lot of doctors, psychologists, school officials, parents, and so on seem to have lost their critical faculties regarding so-called "gender dysphoria" in boys and girls. it's as if they had been brainwashed into joining a cult. I thought Abigail Shrier's 2020 book "Irreversible Damage: The Transgender Craze Seducing Our Daughters" was a well written account of the phenomenon.
I got the "I don't know what's wrong with you" from a doctor followed up with "you aren't dying" and "don't come back". No treatment might often be the right solution but in that case it just appeared she lacked knowledge and empathy.
Intriguing piece. I practiced for 34 years in Internal Medicine, Infectious Diseases, HIV and Critical Care and never gave thought to what a the definition of a diagnosis was. If asked, I probably would have said it was “getting to the right answer so an appropriate treatment can be given”, or something like that.
Early on, however, I saw that every answer I came up with only generated more questions which further enhanced my knowledge and my ability to employ it. Sometimes this led me down rabbit holes where I found something I wasn’t expecting. I often had to admit I didn’t know but I always made sure a coherent plan was in place. I believe that is what is important to patients.
Despite the encomiums I would receive on occasion, by people who are now either dead or too old to remember, what has stayed with me in the twilight of my years is the connections I made with my patients, whether in the HIV Hospice, an ICU conference room or the bedside of someone who was, or wasn’t, getting better. I don’t hear any of that when I speak to the younger hospitalists or specialists and it makes me suspect something has been lost.
Sensible Medicine gives me a chance to reflect on these things.
Sound bad
This is an outstanding commentary that goes far beyond the nosology of disease, and I congratulate you on it.
If I may digress for a moment, I would like to shift the focus from diagnosis of disease to diagnosis of suffering. There are so many ways to categorize and break down human illness, but I would like to give a special shout-out to one of my personal heroes, the late Eric J. Cassell.
Cassell reminded us that when we are ill we experience a disorder, which he described as everything going on within our physiology—altered function—whether or not the patient or physician is even aware of it. He distinguished this from sickness, which reflects how the patient experiences, interprets, and thinks about what is happening to them. These experiences impart meaning to the patient’s life. Finally, he described disease as the pathophysiologic process to which we as physicians attribute the patient’s disorder.
As he memorably stated: “A disorder is what the patient has; a diagnosis is what the physician gives him.” I have always found this to be a powerful and clarifying way to think about health and disease.
But even more important to me was Cassell’s constant reminder that no matter how we classify illness or label disease, the sickness a patient experiences occurs in the whole person, because whatever happens to one part of the person happens to the whole. As he wrote, “it could not be otherwise.”
My comments are merely meant to serve as a gentle reminder that regardless of how we break down diagnosis—regardless of the strength of evidence supporting a pathophysiologic process, and regardless of how rational and effective our therapies may be—there remains a humanistic dimension that sits at the very core of our profession.
I used to remind medical students that I was confident they were becoming skilled at eliciting and appraising a chief complaint of symptoms.
Then I would ask them: How good are you at eliciting a chief complaint of suffering?
I experience a ray of light in the all too often gloom of our teaching hospital:
I saw a young man last week. He was hospitalized due to a combination of bad disease (complications of diabetes etc) and bad choices that had nothing to do with the aneurysm that prompted the consult for me, a surgeon. He and his spouse were cranky for many legitimate reasons,l. After our conversation, stated they were glad to see me because I would “do something and have a plan”. When I responded to a question with “hmmm… I don’t know”, he got cranky again because “that is what the other doctors (nephrologists and hospitalists and cardiologists) keep saying to us”.
This seems more common to me than it was in the past!
There are stronger and weaker arguments in this post. Its weakest parts are the shallow historical argument. The author appeals to a rhetorical question to reduce premodern medicine to practice that forewent investigation and production of material evidence. That is simply not true. Anyone who has read a lot of ancient Greek and Renaissance medicine will recognize the lengths those practitioners went to produce material evidence of their theories. Some examples: They investigated urines and produced diagnostic guides of color wheels to correlate urine color with a humoral diagnosis (Siraisi: Medieval and Early Renaissance Medicine); they used a burn test to distinguish GI causes of hemoptysis from potential tuberculosis (Hippocrates Aphorisms 5.11); in phlebotomy they used measurements of extravasated blood volume and qualitative measurements of the character of the blood against the clinical presentation of the radial pulse to determine the limits of bloodletting (Celsus On Medicine 2.10); they investigated in minute detail the chemical character, shape, and quantity of bladder stones to argue about the composition of the stones and thus the humoral etiology of urinary sediment (Ellis: A History of Bladder Stone). The author also urges us to underscore the limitations of scientific knowledge in communicating to patients our epistemic uncertainty. It is a worthy point, but it is not a valid criterion to distinguish premodern and thus nonscientific medicine from our contemporary medical practice. Premodern medicine is filled with reflection on the limitations of their knowledge and the risk in making diagnoses: some famous texts include Hippocrates The Art of Medicine, Hippocrates Prognostic, Galen The Method of Healing, whose discussions remained influential for much subsequent medieval and Renaissance medicine. I appreciate the author's general point that we would do better to reflect in a philosophical way on the epistemic tools we use to recognize disease and treat patients, but looking closely at the historical record complicates the notion of distance we sometimes try to develop between our own practice and the past.
There’s a new field called philosophy of medicine, a branch of philosophy of science. Why don’t you invite a professional philosopher to write about these things? (See Jacob Stegenga about Gentle Medicine; also the journal https://philmed.pitt.edu/)
I think Philosophy of Medicine should be a first year med school course. No fluff though. Taught by a practicing MD who sees patients. Organized debates during class, everyone needs to participate and speak.
I fully agree with the first year course but to be “taught by a practicing MD” would be a high standard that should be first applied to all the professors and researchers without a clinical practice.
Your making some interesting points in the essay, although I have some objections. I can argue that “truth-seeking” (or pretending) without epistemic humility have contributed to the social polarization today.
I admire MD’s with philosophical reflections but what I tried to highlight is that philosophizing it’s not the same as being a professional philosopher (of science specialized in medicine). Those are experts in metaphysical (what is?) and epistemological (how do we know?) problems. It’s not just conceptual thinking, they work with real problems and sometimes together with researchers and clinicians.
Fair enough.
My general critique of pre clinical coursework is their lack of clinical applicability.
19 weeks of cadaver anatomy. I use hardly any of it.
The biggest application in such a class would be open debate.
Curiously the American Society for Plastic Surgeons and the AMA came out with some hum-dinger statements today without any change in the evidence (or lack thereof from all along).
They were waiting for the cost of speaking up to go down.
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.
Your students are correct. No hospital personnel come to work to critically think how this or that practice or fact emerged. Everyone operates with ready made knowledge — facts and practices. What you encourage them to do is to memorize facts that justify use of standard PPE. Yet you yourself never questions the facts as explanations.
Most in-hospital aka nosocomial infections are self-generated within patients themselves. A patient exhibits symptoms due to some imbalance and his own microflora becomes a conditional “cause” of symptoms that we then counter in a multitude of ways. We essentially decolonize a patient.
How does the use of PPE protect you from your own microflora?
How fast does a person get colonized with environmental flora in a hospital?
Why do patients get infected and visitors and personnel does not?
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 am however vehemently opposed to a God of the gaps belief. Unexplained phenomenon should not be attributed to causes outside of material Reality.
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.
Yes, I think psychiatry is just not there yet. Also, some conditions may be more amenable to change. For most conditions I believe it's at an earlier stage of understanding. More at the "cough diagnosis" stage.
But right now a huge issue is patients assuming an explanatory model always underpins a psychiatric diagnosis. Or medical colleagues believing this. In gender dysphoria this has led to treatment model which assumes a single cause, with the treatment being affirm the young person as they wish. See the AAP 2018 and renewed in its 2023 policy statement led by Rafferty.
The entire treatment pathway for which they advocate, from social transition to surgeries, does not have reliable outcome data.
Long term is particularly important because the surgeries and many of the drug effects are lifelong, including expected sterility for men who start taking the estrogen regimen at any age.
Although MDs talk about assessments, always a good idea, these can flag severe accompanying comorbid issues which may be relevant, but being prescribed medical intervention after being assessed does not mean there is any understanding of whether you are more likely to be harmed or helped by the interventions. One of the clinicians who started the first us pediatric clinic in 2007 said recently that if a young person goes to a gender clinic wanting hormones, they will get a referral for them.
A physician being given the green light to provide puberty blockers, anti androgens, testosterone, estrogen, surgeries may not understand this. The responsibility will include them, though. The asps mentions this responsibility in its excellent statement.
The no debate atmosphere around this condition has led to doctors and patients both thinking this subfield, with it's diagnosis and treatments, is on completely different footing regarding evidence than it actually is.
I quite agree that a lot of doctors, psychologists, school officials, parents, and so on seem to have lost their critical faculties regarding so-called "gender dysphoria" in boys and girls. it's as if they had been brainwashed into joining a cult. I thought Abigail Shrier's 2020 book "Irreversible Damage: The Transgender Craze Seducing Our Daughters" was a well written account of the phenomenon.
See my long article on this topic, A Pediatrician’s Manifesto on the Modernization of Gender Medicine., published on Reality’s Last Stand.
Gender Medicine is fundamentally NOT modern. It is as antithetical to modern medicine as witch burning.
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