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THE LIMITATIONS OF OBJECTIVE STANDARDS
by Robert C. Larsen, M.D., M.P.H.
A number of recent changes regarding reform of the California workers' compensation system place heavy emphasis upon the use of "objective" standards and findings for defining injury and disability. No one would argue against the use of objective information in that process though undue reliance upon such has potential untoward and costly consequences.
The Crucial Importance of Subjective Complaints
One of the hallmarks of modern medical training is the teaching of the diagnostic process championed by the highly respected physician William Osler. Doctors in training are schooled at obtaining signs and symptoms in the course of receiving a "history" from the patient. Typically signs of a disease process include factors that can be observed and measured such as a skin rash or a fever. Symptoms are the subjective complaints put forth by the patient and are of no less value in arriving at the ultimate diagnosis. Medical studies have repeatedly found that the time spent in the patient interview is most valuable. While the physical examination and diagnostic test studies also contribute to making the correct diagnosis, knowing what body part to examine and what test to order follow from obtaining the initial history from the patient while recognizing a pattern of symptoms and complaints that lead the clinician toward knowing what conditions to consider. Undue reliance upon obtaining premature quantifiable evidence can be both costly to the patient as well as to the healthcare system.
Epidemics and the Elusive Nature of Objectivity
Not uncommonly as physicians come to understand any given disease entity the cause of a particular disorder may remain elusive for some time. This does not mean that individual patients suffering with a particular type of illness are any less infirm or disabled than those treated later in time when medical knowledge is more complete. In fact, it is often that patients in the early stages of an epidemic may suffer most and receive the least complete course of care. Before the discovery of a spirochete, patients with tertiary syphilis that had affected their brain were not uncommonly treated as though they had some emotional problem with counseling or even psychoanalytic psychotherapy. Clearly antibiotics would have been a better choice but were not commonly used at the time in treating that infectious disorder. A more recent epidemic that continues to plague the world is AIDS. In the early stages of the epidemic the viral agent was unknown. Today objective evidence of the disease is followed by a number of biologic parameters including T-cell counts assessing the patient's immune system and viral titers actually quantifying the viral load within a given patient. Early on in the epidemic, patients were clearly ill. Symptoms and complaints were no different than they are in that same patient population today but the objective markers were unavailable to confirm the diagnosis. More recently, the SARS epidemic is yet another example in which physicians, epidemiologists and other scientists took time to identify the pathogen. The early victims were no less ill or disabled than someone today who might contract the infection, yet confirmation of the diagnosis was not readily available. Thus, a system that relies solely on objectivity and places insufficient attention upon subjective complaints will result in misdiagnosis, prolonged suffering, public health problems and unrecognized disability.
Occupational and environmental medicine in large part involves the recognition of exposure to toxins and agents found at the workplace and in our environment which places us at increased risk for infirmity. Developing a consensus based upon objective scientific studies takes time. Soon after the surgeon general's report in the 1960s there was little if any change in the behavior of the general population with regard to the use of tobacco. Based upon what some would contend today was misinformation put forth by the tobacco industry, people who smoked continued to do so and those who previously had not became smokers convinced that there was insufficient basis to find a cause and effect relationship between tobacco use and illness. Interestingly, one group whose use precipitously fell in the first year after the surgeon general's report was physicians. Today, what public official would condone smoking on airplanes, in public meeting places or in restaurants? California has been on the cutting edge of legislation in the interest of public health with respect to cigarette smoke. However, for years it was argued that there was insufficient objective basis for finding tobacco to be linked to lung cancer, emphysema and heart disease. The cost to individuals and the society has been staggering. The cost of litigation and liability associated with this crucial public health problem is not in dispute.
Similarly, there have been other examples in which corporations and entire industries have placed their employees and at times the public at risk for chronic illness and infirmity. At times the exposures have been unintentional while at other points one would have to consider that facts support corporate malfeasance. For years the coal mining industry argued against black lung disease being compensable. It took years of scientific experiments and animal models to "prove" the linkage between coal dust and lung disease. Other examples include asbestos and Johns Mansville. The microelectronics industry still disputes the health effects of chemical exposure upon its employees. After World War II it was common practice for soldiers to participate in military drills in which they witnessed nuclear tests. The rate of leukemia and other cancers in that populations cannot be explained by anything other than exposure to radioactive substances. Until epidemiologic studies of sufficient numbers of victims allowed for that conclusion, all physicians had as evidence was patient complaints and histories. For those who would argue that in today's world such exposures will no longer take place, perhaps the lessons of history have yet to be fully learned. After the first Gulf War in the early 1990s members of the armed forces returned complaining of a host of vague symptoms. Fatigue, weight loss, moodiness and concentration problems were attributed by physicians in the Veterans Administration to combat fatigue, depression and even malingering. Objective abnormalities were scant in soldiers diagnosed with Gulf War Syndrome. Now years later we realize that many of these veterans had been exposed to the dust from munitions designed to penetrate armored vehicles and bunkers. Tens of thousands of projectiles hardened by uranium contaminated the battlefields with low grade radioactive material that has a half life of thousands of years. Thus, misdiagnosis, improper treatment and a denial of disability benefits took place in individuals with legitimate injuries.
Requiring Objective Evidence Will Increase Costs
There are many reasons why healthcare costs have expanded in recent decades in the United States. Factors include the aging population and the expansion of medical technology. If physicians are required to demonstrate objective findings in all cases where injury occurs, there may well be unintended consequences of increased costs rather than savings to the system. Where an x-ray may suffice an MRI scan will be ordered. Where subjective complaints would be sufficient to institute treatment, blood chemistries will be ordered.
Let us examine the field of medicine that commonly is considered to have the most subjective grouping of disorders. The general population has the impression that psychological problems and mental illness are merely labels for problems of living. A skilled psychiatrist can diagnosis a major depression as opposed to a panic disorder or schizophrenia in a given patient. Different treatments are instituted whether using an antidepressant, an anti-anxiety drug or an antipsychotic medication respectively. Of course there are other elements to the treatment of these disorders. If physicians are required to objectify their patient's illness they will do so. Studies of metabolites of neurotransmitters excreted in the urine or present in the cerebrospinal fluid can be obtained. Functional MRI scans or PET scans of the brain can be obtained. In most cases this will not alter the treatment or outcome of the disorder. Many of these studies are used currently in clinical research but have limited value in office practice. However, if standards are required by the disability system to document disease and sophisticated diagnostic tests will most certainly be ordered and the cost will be potentially enormous. Other conditions such as fibromyalgia which has a vague constellation of complaints has now been found to have biological markers. Treating and evaluating clinicians in pain programs will be obtaining assays of Substance P from their patient's central nervous system if necessary. If policy makers require employees and their representative to demonstrate in all cases objective abnormality, then consideration should be given for what is being demanded. Perhaps rather than reducing the cost of disability awards there will be a commensurate increase in the cost of diagnostic testing and some higher unexpected disability awards.
Summary
In conclusion, the time honored practice in medicine of respecting subjective and objective evidence should not be dismissed. Untoward consequences of current proposals to do so include misdiagnosis, disenfranchising the disabled and increasing diagnostic test expenses within the workers' compensation system. Qualitative and quantitative findings have merit when determining medical issues involving diagnosis, causation and disability.