We chaplains pride ourselves on being able to see and hear what’s happening in a given situation without presumption so that we can help patients and their caregivers understand the subtext of what is going on with them- especially spiritually and emotionally. We often quote Theodor Reik and say we are able to “listen with a third ear”. We try not to be hampered by stereotypes or categories.
There are problems with this approach of course. First, we don’t achieve this goal to the extent we would like to think, and in deluding ourselves on this point, we miss some useful information which a presumption born of experience and knowledge can lead us to. We fail to recognize that our presumption (diagnosis?) is often right and helpful in planning treatment. We also are unable to communicate clearly to the other members of our team because we use very general language that doesn’t help them meet the patient’s needs.
This all said, it is true that settling on a diagnosis too quickly without considering all other alternatives can lead to mistreatment. One easy pitfall here that I’ve become more aware of recently is settling on a diagnosis that is true but does not represent or address the root issue. One example most of us in health care would be aware of is the patient- child or adult- who shows up in the ER or doctor’s office with an injury and the story for how this happened doesn’t seem to fit or make sense. Any good clinician of any discipline would at least entertain the possibility that this injury is due to abuse or neglect and not simply diagnose a broken bone or contusion.
I recently read an article on how often elderly patients presenting with repeated infections, depression, or “wasting” might really be, at root, malnourished. We see more in the literature and news media about children who present with what appears to be a school phobia or avoidance of other social situations who are the victims of ongoing bullying. The victim of a single car accident due, on the surface, to alcohol or drug use may be, at root, suffering from PTSD and be self-medicating. In my own field, the evidence is increasing that some patients who present with anxiety or depression are, at root, suffering from spiritual distress that will not be effectively treated with medication. In all of these cases, the initial diagnosis is not wrong, it simply represents a symptom and does not represent the root cause of the problem.
Treating the symptom is not a wrong decision. The bone of the abused child needs to be set. Medically reducing the anxiety of the person with spiritual distress will likely make it easier for them to deal with their spiritual issues. And it is true that effectively treating the symptom often helps reveal the root cause.
However, this all does point up for any who are clinicians in any discipline the necessity to not settle on a final diagnosis too quickly. In doing root cause analysis, the quality improvement folks often employ a method called “the five whys”. There is nothing magical about the number but the idea is that, getting to a root cause most often necessitates asking “why” several times on the same issue to get down to the core of the problem.
Given the pressures of practice today in any discipline, it is too easy and convenient to settle on the obvious diagnosis or presenting issue and move on. We don’t generally get rewarded currently for a root cause analysis. In fact, raising a root cause issue has often been punished. Further, many of these root cause issues represent broader social problems like support for the elderly, care of vets or a culture that too often does not provide people with meaning and community. However, I think the system is realizing the costs of missing a root cause- both to the patient and to the system itself. The elderly patient who makes repeated ER visits that could be prevented by nutritional counseling and monitoring could save the system a lot of money. Thus, opening a senior center that provides meals and nutritional counseling might be a worthwhile investment for a hospital.
I am more and more convinced that we as health care providers need to break out of our traditional practice model which is restricted to seeing the patient in front of us, treating the presenting symptom or, in the case of chaplains, dealing with whatever the patient wants to talk about and moving on to the next patient. We chaplains often convince ourselves that if we listen to patients, respect them and affirm their situation, that is enough. However, we see the effects of some of the broader social issues in our clinics and our EDs. We see what these issues are costing individual patients and families and the health care system itself. It is time to share this knowledge in a more open way and join the conversation on how to provide treatment for root causes and not just presenting symptoms.