|Posted by Margaret Donohue on September 6, 2015 at 8:50 AM|
The research studies go back to the 1930's and were quite prolific through the 1970's. Most involved individuals admitted to psychiatric hospitals as the result of severe symptoms of depression, anxiety, mania, psychosis, or neurotic symptoms. The rates of undiagnosed medical illness CAUSING the symptoms ranged from 10% to 50% and of that population, 77% had a complete remission of symptoms when the underlying medical condition was treated.
Back in the late 1970's when I was in graduate school, the field of Medical Psychology was being created. It was conceptualized that Medical psychologists would work in physicians' offices to assist with diagnosis and differentiation of medical and psychiatric symptoms. We would refer back those patients with medical conditions for further evaluation and treatment and continue to treat psychiatric symptoms with psychotherapy and also address issues of compliance with medical treatment. To that end, we were taught to take thorough medical histories, do medical symptom evaluations, perform basic vital examinations such as heart rate, respiration rate, blood pressure, height and weight, and temperature. We were also taught to recognize medical symptoms through an understanding of clinical medicine.
Clinical medicine existed at the beginning of the field of medicine. It is the evaluation of a patient by looking at them and listening to them. It predates laboratory medicine by thousands of years. The field of clinical medicine is generally no longer taught in medical schools. It's been replaced by laboratory medicine described as "more accurate and evidence based." But it's not.
Ideally, clinical medicine should allow for an andequate index of suspicion to present for laboratory based medicine to confirm symptoms and establish a diagnosis. But if a physician relies only on laboratory based medicine they will miss anywhere from 12-25% of cases where the laboratory findings are just under abnormal, but still indicative of disease. In psychiatric illness, where diagnosis by general physician is based on symptom report or rating scales, the error rates skyrocket.
I have some rare genetic condition, one of which is low blood volume. That means my labs are normal even when I have obvious manifestations of disease clinically. Physicians trained in medicine after 1985, have little to no training in clinical medicine and will inevitably pronounce me "normal" and "healthy" even if I'm fainting in their office, pale as a ghost, bruising easily, complaining of long muscle pain, tongue scalloping, and tongue burning--all symptoms of significant anemia. If they finally look up from their lab sheets, they will confusedly remark "but your labs are normal!" As a result I became invested in learning as much clinical medicine as I could.
I started off working for a general physician right out of graduate school. The majority of missed diagnoses were of endocrine disorders, anemia of chronic illness and malignancy, cardiac conditions, lung conditions, kidney disease, substance abuse and poor nutrition. He was a good physician. The difference between what he was doing and what I was doing was in taking an adequate history. He had 10 to 15 minutes to see a patient, establish a diagnosis, order labs and tests and write a prescription. I had an hour and, if needed, I could take 90 minutes. It makes all the difference.
So here are the people I treat: