‘Delicate diagnosis’: avoiding harms in difficult, disputed, and desired diagnoses

<p>Medical diagnoses can be subject to ambiguity, flux, subjectivity, and inherent uncertainty. This is particularly true in primary care, where many reported symptoms do not conform to a clear diagnosis. Thresholds around normality are often unclear.</p> <p><br></p> <p>Symptoms are commonly experienced and described as an ’iceberg’. Over a third of otherwise well people without a chronic condition have felt tired or run down, or had a headache in the previous 2 weeks, and over a quarter have had back or joint pain. Distinguishing conditions that would benefit from diagnosis and earlier intervention from those that are temporary, self-limiting, and prone to harmful medicalisation, remains challenging.</p> <p><br></p> <p>While overdiagnosis is a diagnosis of a condition that, if unrecognised, would not cause symptoms or harm, contested diagnoses are symptoms given a diagnosis, but where the diagnosis, as an explanation for them, is controversial. Opponents consider contested diagnoses ‘wrong’ not because of an error in history taking, clinical examination, or interpretation of a test result (which would risk misdiagnosis), but because the diagnosis itself, for example, chronic Lyme disease or multiple chemical sensitivity, is invalid.</p> <p><br></p> <p>Contested diagnosis is bordered by ‘pseudoscience’, for example, adrenal fatigue, leaky gut syndrome, and chronic candidiasis, which attempt to explain symptoms with ‘science’ that is demonstrably incorrect.</p> <p><br></p> <p>Many contested diagnoses relate to symptoms that are not clear-cut, meaning that some people are given a diagnosis that does not confer benefit. Others are primarily unexplained ‘yet’. For example, Gulf War syndrome was treated as a contested illness but is now recognised as caused by exposure to sarin gas. Other recognised conditions are prone to a variety of influences such that diagnosis risks causing harm, through a variable mixture of misdiagnosis, overdiagnosis, pseudoscience, or overtreatment.</p> <p><br></p> <p>A framework for considering some conditions as ‘delicate diagnoses’ may help to recognise and reduce the harms of medicine in these circumstances.</p>