To the Editor: In my transition from medical student to pathology resident, I found myself at the front line of medicine’s definitional arm. I was tasked with interpreting tissue and putting a name to my patient’s suffering in the form of a diagnosis. When it came to tumors, it became my job as the pathologist to predict the life cycle of that mass with a single word: benign or malignant? Happy ending or tragedy?
During medical school, much of the focus was on learning what actions to take to diagnose or treat a particular disease. A physical finding, scan, or lab result led to a diagnosis as if by mathematical formula. Discussed far less frequently was how central the role of epistemology (“knowing how we know”) would be in the lives of patients. New interns can list the causes of hyponatremia, but can they explain why exactly “hyponatremia” is a disease, or when it might not be?
As I learn more pathology, I see the uncertainties inherent in medicine’s definitions. Cancer is not merely cancer but a product of philosophy, linguistics, and probability. I have been surprised to learn how much the undergraduate medical curriculum downplays the importance of epistemology on disease screening, overdiagnosis, and overtreatment. As a medical student, talk about these topics was theoretical physics—impossible to connect to real practice. As a pathologist, my definition of disease has become an atomic bomb leading directly to patient care and well-being.
My classmates were anxious about their internships as we neared graduation: How would they answer that midnight page or run a code? Personally, I wish I had been better prepared for the daily questions I would face about diagnostic thresholds and the indistinct boundaries among “different,” “abnormal,” and “pathological.”
As I transitioned into residency, I would have valued a curriculum that historically contextualized diagnoses, emphasizing their overlaps and uncertainties. The preparation for residency could better equip medical trainees to appreciate the doctor’s role as label maker. It could make explicit connections between the language physicians use and its effect on a patient’s identity and outlook and on society’s culture. For physicians in practice, a diagnosis is no longer merely an answer on a multiple-choice test, but an act that immediately transforms patients and community.
Prepare us not just to know, but to ask how we know.
Benjamin L. Mazer, MD, MBA
Pathology resident, Department of Pathology, Yale-New Haven Hospital and Yale University School of Medicine, New Haven, Connecticut; [email protected]; Twitter: @BenMazer.