My friend Dr Richard Low and I have long been aware of the reality that: "The state of health that the patient has, has less to do with what is wrong the patient, than it has to do with what the doctor thinks is wrong with the patient."

This attitude became known to me early in medical school when I competed (on behalf of my school) against medical students from each of the other medical schools in Quebec. It was an annual "Clinical Pathological Conference" competition in which each school's representatives (2 students) were given a 1 page summary of a case (diagnosis not supplied). We were given a week to prepare our analysis of the case and we presented our arguments for what each team thought was the "final diagnosis" in front of a panel of judges (professors all).

I was initially astonished that we didn't all come up with the same diagnosis. Of course, had the situation been true that the diagnosis was inevitably contained in the summary, there would have been no point in having a competition in the first place. So, I realized that the diagnosis was not inevitably contained in the summary. I reasoned at the time that even if each team had been given the entire medical record (minus the final pathology report which revealed [in this instance post-mortem] the final and "correct" diagnosis) we would not all have come to the same conclusion/diagnosis.

Throughout the succeeding years I saw innumerable examples of such "disconnections" between what we considered objective data and the "correct" diagnosis. For example, a patient would be referred to me for management of "Graves disease" but the patient did not have Graves disease. Rather the patient had "subclinical hyperthyroidism." That's a different entity whose differential diagnosis happens to include "Graves disease in remission" but is not synonymous with Graves disease. Had I not seen the patient, treatment for Graves disease may have been initiated, with undesirable outcome. So I have realized that I was making a living [as an endocrinologist] partly because of this disconnection between medical diagnostic information and the "correct" diagnosis. In other words, what was wrong with the patient had more to do what what we as physicians thought was wrong with the patient than what was actually wrong with the patient.

More than 10 years ago I first became aware that not everyone had my attitude toward this topic. If I had given it any formal thought I would have assumed that everybody inplicitly knew this fact. I became aware of the situation as the result of a statement that Dr Low made a Newsletter dealing with his EMR. He said that "what is wrong with the patient has nothing to do with what disease the patient has; it has everything to do with what you as a physician think the patient has."

Clayton L. Reynolds MD