The Dying Art of Diagnosis: The Failure of the Magic Checklist in Psychiatry


Have you noticed that a lot of healthcare is now delivered by following preset guidelines, instead of creating unique solutions case-by-case? If you go to the doctor complaining of chronic sinus pressure, they may send you to the allergist because sending you to the allergist is the “protocol” - without hearing or understanding that you’ve tried all the available allergy treatments and the problem persisted anyway.

We all know someone who takes too many psychiatric medications and doesn’t seem to be improving, and the lost art of diagnosis is often the cause. The “protocol” in mental health is often the use of a checklist. If you have the symptoms from the list, then your problem is bipolar disorder, for example. Never mind that you had a decade of successful treatment for depression and anxiety (which should have made you worse if your problem was misidentified). Or never mind that you have horrific traumas in the past: you were held hostage and beaten and sexually assaulted. Never mind anything unique about your case or your history. The checklist says you have bipolar disorder and that’s what you have. Period.

When the checklist says you have the diagnosis, but the treatment fails to help, mental health professionals often double down and add more meds. Because they feel certain about the original diagnosis.

This problem isn’t unique to mental health treatment, but the consequences play out differently here. Whereas the sinus problem (or any physical ailment) goes undertreated, the inevitable error in mental health is that the problem is overtreated. Medications are layered on upon one another in an attempt to stabilize hidden, hard to measure symptoms.

That’s how your loved-one ends up on 6 psychiatric meds, and still has the symptoms she sought help for in the first place.

Why is this happening?

Well for one, healthcare professionals are trying to see too many patients, shortening the time with each person. We can all see that asking a professional to squeeze in more patients in shorter appointments has failed, but it is still the expectation of the hospitals, insurance companies, and the payers. If a checklist could work, it sure would save time.

And secondly, in an effort to ensure better care, checklists and algorithms are encouraged or even required by regulators and overseers, based on the assumption that healthcare is safer when the same steps are followed every time.

But good diagnosticians don’t use checklists, they use experience, pattern recognition, and a finely trained ‘eye’ for identifying the most important pieces of the puzzle. The right diagnosis depends on recognizing what is unique in each case, not approaching every case the same way. And the right treatment relies on starting with the right diagnosis.


Posted on February 4, 2019 .