PERIPHERALIA

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There are many pathways and trajectories that patients 
take on their way to seeking medical attention and to a 
final diagnosis. The journeys may start with the symptoms 
themselves or with prompts from the environment around 
them. This information that motivates people to seek medical 
attention may come from the ubiquitous modern media, or 
from online information or misinformation. Prompts to seek 
healthcare may also come from the illness experiences of 
relatives, friends or colleagues.

While on the way to see my own doctor I carefully go through, 
in my mind, what I am going to say to her and usually have 
already terrified myself with the diagnostic possibilities of 
my symptoms. On arrival we talk about our mutual social 
lives (called phatic communion) and then proceed to the 
symptoms themselves, but by this time I have lost the thread 
of my neatly ordered history. I begin in the middle and 
embellish a mixture of patchy stories with added digressions 
on what I believe are the causes of my symptoms.

During this process, it is difficult for her to separate the wheat 
from my chaff, but this is often the process that we have to go 
through with our patients. They now arrive with already half-
formed ideas of their diagnoses, which they have received 
from the morning radio talk show. 

Self-diagnosis or diagnosis by a doctor does not necessarily 
occur as a once-off event (called a diagnostic moment), but is 
often an accumulative process. There is firstly a stirring in the 
mind which is then followed by a pathway of consultations 
and investigations that eventually ends in the diagnosis 
(called the pre-diagnostic trajectory). In many cases these 
days, the initial stimulus may not be made by the symptoms 
themselves, but may be started by prompts or cues from 
information received from outside the patient. These are the 
inchoate, semi-formed thoughts that often arise following 
health screening or education programs.

In this lead-up, we start to assemble evidence in our minds 
(called diagnostic assemblage) which sets our thoughts in 
order (or in my case out of order). This then initiates our 
health seeking behaviour. There are also those chance pieces 
of information that we pick up as “snippets” from overheard 
conversations or from passing media programs.

What follows is the trajectory to seek help from a significant 
family member, respected acquaintance, the pharmacist 
or medical practitioner. The pathway often includes an 
alternative or traditional healer where a culturally-based 
causation may be added as well.

We can actually jog along for quite some time either denying 
or suppressing the possibilities of various diagnoses until an 
event or additional information is received, which kick-starts 
the process of proactively seeking a diagnostic label.

When I started practice in the late 1960s my patients were 
diagnostically naïve with very limited knowledge of the 
functions of the body and its ailments. I have watched over 
the years as education has improved and now my patients 
are mostly well-informed. By the time they see me they may 
“know” their clinical diagnoses (or misdiagnoses) although 
these may not be fully articulated or formulated in their 
minds. I have the impression that most of them do not inform 
me of these prior labels or names that they have formed 
but wait to see whether I will confirm them or propose 
alternatives.

At this stage I find it useful to ask the patient what they 
believe are the causes of their symptoms. The preconceptions 
can then be laid on the table and either followed up or other 
avenues can be negotiated. The patient may make several 
subtle offers during their presentations and these can then 
be taken up and discussed. Suspicions and anxieties can 
often be allayed at this early stage. During this journey there 
is a continual heuristic process of either acceptance or denial 
and some bargaining with one’s own health, religious and 
cultural beliefs.

Along the way there may also be “accelerators” to the 
patient seeking help, such as a telephone call received after 
a laboratory or imaging test has been done. The patient is 
alerted to the fact that something may be wrong when 
requested to attend for a hastened follow-up appointment 
with an urgency that has not been anticipated. Suspicions 
may be confirmed at the follow-up consultation by small 
changes in the normal routines (called breaks in the ceremonial 
order of the medical consultation). The patient picks up on the 
non-verbal communication of the doctor’s demeanour and 
the give-aways of over-sympathetic comments by the staff. 
Even slight deviations in protocol such as the rearrangement 
of the chairs as well as significant silences are causes of 
heightened awareness in the patient. Although these are 
seemingly minor changes, they may be deeply significant to 
the patient (called the salience of the prosaic). These are the 
small incidents that may alert the patient to the fact that 
something is wrong, such as when the ultrasonographer, 
who has been merrily chatting away, suddenly goes silent. 

We now live in a world overloaded with information that is 
within easy access of our patients. If I have time, I try to briefly 
ask about the routes and trajectories that the patients have 
made before seeing me. It often expedites the outcomes as 
well as allaying their diagnostic anxieties and uncertainties.

Chris Ellis is a family physician in Pietermaritzburg, 
KwaZulu-Natal

E mail: cristobalellis@gmail.com

The pre-diagnostic trajectory