Missing the psychosocial diagnosis—a form of institutionalised malpractice

All too often clinicians overlook the potential psychological diagnosis in front of them, argue Bruce Arroll, Robert L Phillips Jr, and David R Kuhl

We see it almost every week. A discharge note from an acute care clinician with a diagnosis of “non-cardiac chest pain” or musculoskeletal chest pain. The patient, a 22 year old female, for whom there is essentially zero chance of cardiac chest pain, has had an ECG, chest x-ray, and blood work for cardiac enzymes—all are normal. It is surprising that there is no mention of any psychosocial component. We wonder why the words “panic attack” or “anxiety” are not mentioned. These kinds of cases are surprising, but sadly commonplace, as all too often clinicians overlook the potential psychological diagnosis that is in front of them. We consider this a misdiagnosis, and in that context an act of malpractice.

In order to capture the essence of this “practice” we would apply the term “institutionalised malpractice,” as in our experience most physicians do it. Like institutional racism, institutional malpractice is a long term, behavioural bias, which is borne more out of inertia than intent. However, if this is our modus operandi, we do our patients and ourselves a disservice.

Physicians need to be cautious when making a diagnosis of absence, i.e. non-cardiac chest pain, and broaden their diagnostic sieve to include the psychosocial context. Many physicians perhaps don’t see it as their role, but the acute care clinician from the above example could, at least, offer an understanding response, “I think you may have stress/anxiety. It would be best to discuss that with your GP.” In the perfect clinical world this would be a natural and expected comment. Avoidance of any psychosocial issues will likely only result in repeated visits to some component of healthcare.

There are many reasons why doctors may not make a mental health diagnosis, even if they are aware that the patient is experiencing psychological distress, and qualitative research has elicited from doctors some of the most common ones. Firstly, doctors are generally trained to explore the physical aspects of illness first, based on the premise that it is bad practice to miss a physical diagnosis but less problematic to miss a mental health diagnosis.[1] Some doctors prefer not to deal with mental health issues.[1] Some are reluctant to explore psychosocial issues in case they open Pandora’s Box.[1] (Ironically, hope lies at the bottom of this Pandora’s Box.) Some avoid doing so due to a lack of confidence or perceived incompetence in raising mental health issues.[2] Some doctors have concerns about stigma for the patient, while others are concerned about the impact a diagnosis of depression will have on a patient’s future insurance claims if it is recorded in their medical records.[1]

Underlying all this, we’d suggest that we clinicians shy away from psychosocial issues as often our personal and clinical resources do not allow for us to venture into that domain. As the primary care poet Glen Colquhoun said, “I saw a young woman for a repeat prescription. Her story was so large I knew not to ask about it in the morning when the day is fragile with need.”[3] He rightly makes the point that on some days we do not have enough resources or resilience to venture forth.

In an article about the need for healthcare to respond to suffering, not just specific conditions, authors Epstein and Back comment that “suffering can make physicians feel helpless.”[4] Too often, they argue, when feeling helpless we withdraw—by referring to another specialist, scheduling the next follow-up appointment in the distant future, or blaming the patient. We would add to that list: “making a biomedical diagnosis when a psychosocial diagnosis is more appropriate.”[5] At times, we seek to address an emotional need with a cognitive response. That, in itself, might add to the patient’s suffering.

This phenomenon touches upon medically unexplained symptoms, which has been a focus of research.[5] Data from tertiary care has previously revealed very high rates of medically unexplained symptoms, with one study giving an average of 52%.[6] While an older study to determine the incidence, diagnostic findings, and outcome of 14 common symptoms (e.g. headache, back pain, insomnia, constipation etc.)[7] estimated the probable etiology was that 16% of symptoms were organic, 10% psychological, and 74% unknown. The authors said that “although only 10% of the symptoms were classified as psychological it is probable that many of the symptoms of unknown etiology were related to psychosocial factors. Patients with depression, anxiety, or stress present with physical rather than affective complaints.” They also said that “diagnostic and therapeutic strategies focusing solely on organic causes may be inappropriate for the majority of patients.”[7] Our view would be that not much has changed in the intervening years.

The solution to this for both the patient and the physician is to turn towards the suffering. To be in a healing relationship means that we must stay present in the suffering of others. Indeed, given the complexity of modern medicine, we’d argue that the doctor who can hold the biomedical and the psychosocial diagnoses simultaneously will be the one with the better job satisfaction.

When we chose the term “institutionalised malpractice,” it was carefully done. Physicians need to resist institutional pressure to meet volume and administrative targets when this compromises considering their patients’ psychosocial state and wellbeing. Persisting with institutionalised malpractice serves neither the patient, clinician, healthcare organisation, nor society as a whole. Perhaps there is value in remembering the apposite quote of our co-author David Kuhl, “What we know, cures and who we are, heals.”[8]

Bruce Arroll is a professor in the Department of General Practice and Primary Health Care at the University of Auckland, New Zealand.

Competing interests: None of the authors have any financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work. There has been no external funding for this paper.

Robert L Phillips Jr is the vice president of research and policy on the American Board of Family Medicine.

Competing interests: None of the authors have any financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work. There has been no external funding for this paper.

David R Kuhl is a professor in the Departments of Family Medicine and Urologic Sciences at the University of British Columbia, Canada.

Competing interests: None of the authors have any financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work. There has been no external funding for this paper.

Contribution: BA came up with the idea and all authors contributed to the paper.


[1] Dew K, Dowell A, McLeod D, et al. “This glorious twilight zone of uncertainty”: mental health consultations in general practice in New Zealand. Soc Sci Med 2005;61(6):1189-200.
[2] Maxwell M, Harris F, Hibberd C, et al. A qualitative study of primary care professionals’ views of case finding for depression in patients with diabetes or coronary heart disease in the UK. BMC Fam Pract 2013;14:46.
[3] Wilson H, Cunningham W. Being a Doctor Understanding Medical Practice: Published by Otago University Press. 2013.
[4] Epstein RM, Back AL. A piece of my mind. Responding to Suffering. JAMA 2015;314(24):2623-4.
[5] Williams N, Wilkinson C, Stott N, et al. Functional illness in primary care: dysfunction versus disease. BMC Fam Pract 2008;9:30.
[6] Nimnuan C, Rabe-Hesketh S, Wessely S, et al. How many functional somatic syndromes? J Psychosom Res 2001;51(4):549-57.
[7] Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989;86(3):262-6.
[8] Kuhl DR. Keynote talk ” What we know cures and who we are heals.” In: https://www.goodfellowunit.org/symposium/programme#day1, ed. Goodfellow Symposium, 2017.