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CAREERS OF ILLNESS: PROBLEMS IN THE DIAGNOSIS OF CHRONIC ILLNESS G. GAYLE STEPHENS* Circulating among the universe of patients in our medical care system is an indeterminate but large subset whose ancestor was described in the Bible (St. Mark 5:25-26): ... a certain woman which had an issue blood twelve years and had suffered many things of many physicians, and had spent all that she had, and was nothing bettered, but rather grew worse. In some respects these patients, who are not all women, are well known to the medical profession in picturesque, pejorative language as "crocks," "squirrels," "neurotics," "gomers," "difficult patients," "hateful patients," "medical care abusers," and, God forbid! "dirtballs." In other respects, though, they are hardly known at all. They frequent all sorts of health-care facilities and consume disproportionate quantities of services—usually with very limited benefit. They defy our attempts at cure, and the care they receive seems often unsatisfactory or even contributes to more health-seeking behavior. Orthodox physicians tend to find such patients a burden, while irregular healers cater to their idiosyncrasies and exploit their beliefs. My interest in such patients stems from 30 years of general practice, a perspective that affords abundant opportunities to see patients of all ages and both sexes who manifest the broadest spectrum of clinical conditions. General practice also provides a unique opportunity to see patients both early and late in their illnesses, as well as in the middle stages, and to see patients who have already seen other physicians, generalists and specialists alike. Everybody knows that GPs provide priThis paper was presented at the Academy of Psychosomatic Medicine meetings, Las Vegas, October 1983. *Professor, Department of Family Medicine, School of Medicine, University of Alabama , Birmingham, Alabama 35294.© 1986 by The University of Chicago. AU rights reserved. 0031-5982/86/2903-0478$01.00 464 I G. Gayle Stephens ¦ Careers ofIllness mary care and that specialists provide tertiary care, but not many realize that we also provide a substantial amount of quaternary care, that is, posttertiary, which is the care that is needed after "everything has been done" and "medical science has done its best." From my point of view, there is a good deal of diagnostic and therapeutic uncertainty in the management of the chronic patients under discussion. They do not seem to fit standard classifications of diseases and mental disorders. They present mainly symptoms and complaints that do not constitute a single, named disease or disorder; they may show no abnormal physical findings, ambiguous findings, or the findings of an acute or chronic disorder that are merely incidental to the larger pattern of illness. Moreover, the symptoms tend to change from time to time, though some do not, suggesting multiple organ system problems, but, even more, the body as a whole. They are peculiarly resistant to classification by analysis of parts, and no appropriate classification by synthesis is available. A patient whom I saw recently for the first time illustrates the taxonomic problem. She was a young woman who complained of diminished hearing in one ear since childhood, but recently in both ears; urinary frequency without dysuria and nocturia three to four times nightly; and insomnia. She was taking Desyrel® and an oral contraceptive. She had complete urological evaluation at a university medical center 3 years before and was told, as she remembered it, that the symptoms were caused by stress. Following that, she went to a mental health clinic in another state where she participated in counseling with a psychologist and received Desyrel® from a psychiatrist whom she saw occasionally, presumably for "med-checks." I discovered impacted cerumen in both ears, and the patient was astonished at her improved hearing after the wax was removed. A urinalysis was normal—and disappointing to the patient. She had been taking Desyrel® for 3 months at a top dose of 300 mg daily, but had gradually reduced it to 50 mg and then stopped altogether 3 days before she saw me. That is when she became insomniac and wondered whether she should begin taking it again. How should I have coded this office visit and classified this patient? What is the proper name or names of her medical...

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