The problem or diagnosis listed opens doors for treatment and payment, but is often an approximation of the patient’s clinical problem rather than a definite diagnosis supported by the medical evidence. Just as a map is not the territory, but a representation of the territory, an EHR diagnosis is a representation of a patient’s health status that allows the healthcare delivery system to pigeonhole a patient for purposes of medical evaluation, management and reimbursement.
Ever-increasing non-medical demands, including data entry into the EHR, often result in uncritical acceptance of a listed diagnosis or problem at face value. Very little energy is left for critical thinking and intellectual honesty given the pressures on the healthcare provider to please the customer and be productive. Yes, healthcare is now a business transaction between a provider and client, a transaction that has to be validated and approved by the entities that ultimately pay for the healthcare services. Whatever “diagnosis” gets the job done is the basis for future healthcare services (even when the diagnosis is not really certain). In an effort to prevent having a dissatisfied customer, which can adversely affect the healthcare provider’s performance evaluation and value, no attempt is made to address the patient’s self-defeating thoughts and behaviors even if time allows.
Forces of fashion, politics and economics drive diagnostic labeling from being a thoughtful intellectual construct to a diagnostic hunch based on inductive reasoning with assumed pathophysiology, even though examination and diagnostic testing cannot establish diagnostic certainty.
A diagnostic hunch is not the same as a diagnostic fact, even though the patient and healthcare delivery system may be satisfied. The ever-growing list of diagnostic labels used to justify healthcare services is not to be taken at face value so the service transaction can be completed and allow the provider to go on to the next patient while looking good on paper.
Often, marginal or non-specific diagnostic laboratory findings are the basis for a diagnostic label that appears to be definitive and not just descriptive. These diagnostic labels, often from multiple providers, need to be critically reevaluated over time and not accepted just because they are on the record. These diagnostic labels soon are treated as established and accepted diagnoses that serve as the basis for evaluation and therapy.
Often, valid but unproved medical theories and findings are reverse engineered to explain unexplained symptoms that are resistant to diagnosis and treatment. Many of the symptoms are the body’s response to stress and abuse, which only the patient can address and are not amenable to surgical or medical therapies. The diagnostic labels serve to justify ineffective therapeutic and diagnostic efforts. The more physical complaints and symptoms, the more diagnostic labels—both correct and incorrect—accumulate over time.
