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Sports physiotherapyMay 17, 2021

Sports medicine experts warn that labelling patients' conditions can have an unintended 'dark side'

Clinicians who strive to attach diagnostic labels to their patients’ conditions should be aware that the practice can have an unintended ‘dark side’.

That is the message contained in a British Journal of Sports Medicine editorial, written by Daniel Jonah Friedman, from Alfred Health in Melbourne, Australia, and colleagues.

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There is a dark side to the face of the diagnostic label, the BJSM editorial warns

Physique
Physique

The plus side of labelling

On the plus side, Dr Friedman and his two co-authors, Louise Tulloh and Karim M Khan, acknowledge that a diagnostic label ‘captures a textbook chapter’s worth of information’.

‘It helps characterise and organise people's conditions within definable boundaries. Just as a patient wants to find a cause for their woes, we clinicians pride ourselves on identifying it.’

The 'dark side'

There is a dark side to the face of the diagnostic label. A label implies that the clinician knows the specific tissue pathology that is causing pain or dysfunction [Daniel Jonah Friedman and colleagues]

There can, however, also be a downside: while a clinician may be skilled in assigning labels, they can be unnecessary and lead to healthcare resources being wasted, the authors warn.

‘There is a dark side to the face of the diagnostic label. A label implies that the clinician knows the specific tissue pathology that is causing pain or dysfunction.

‘In sport and exercise medicine, accurate tissue or pathoanatomical (‘structural’) diagnosis is often impossible; when a person presents with low back or knee pain, special tests and imaging do not necessarily reveal the cause.’

'Mechanistic’ labels – such as calling disc disease ‘degenerative’ or describing a meniscus as being ‘torn’ – can have ‘catastrophic’ consequences for the patient, who may become anxious and afraid of movement, the editorial suggests.

Different interpretations

‘Each person interprets each label differently – many labels have negative connotations. If a diagnostic MRI in a person with knee pain describes a meniscal tear, this may nudge the patient (and clinician) to prioritise options such as arthroscopic surgery that are not indicated as first-line therapy.’

The editorial makes it clear that exceptions can be made when an acute problem emerges. It would, for example, be ‘paternalistic’ to avoid telling a patient he or she has torn a hamstring during a sprint – even if the aim was to reduce their anxiety.

‘But even in these seemingly straightforward circumstances of acute, obvious injury, clinicians’ language profoundly affects patients’ attitude towards the injury. For example, a patient may consider a “broken bone” to be significantly worse than a “crack in the bone”.'

Chronic conditions

Turning to focus on chronic conditions, the authors suggest that labels abound in the field of sports and exercise medicine that 'reflect normal findings in asymptomatic individuals'.

'When imaging reveals incidental structural changes such as joint space loss or subchondral sclerosis that does not relate to pain and dysfunction, what is the benefit of a label that may harm the healthy? When clinicians then emphasise osteoarthritic "wear and tear", are we surprised that people avoid movement and anticipate a poor prognosis?

Strategic labelling

The authors set out a framework for using labels constructively, which is summarised below

  • embrace the non-specific regional label. A label should be a constructive and dynamic guide that helps validate an individual’s experience. It is not an endpoint
  • ‘de-label’ if the risk is low. Can clinicians resist the temptation to attach a diagnostic label to transient indeterminate symptoms?
  • if the electronic medical record demands a label, explain to the patient what the label means – and doesn’t mean
  • remember that words can hurt. Avoid using concrete degenerative terms such as ‘wear and tear’ in overuse conditions, and use ‘overloaded’, ‘irritated’ or ‘aggravated’ instead

 

To see the full version of Peeling off musculoskeletal labels: sticks and stones may break my bones, but diagnostic labels can hamstring me forever, visit: 
http://dx.doi.org/10.1136/bjsports-2021-103998

Author: Ian A McMillan
Physique
Physique
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