Theme Two
What a name does
Does the label describe the disease, or help bring it about?
A diagnosis is supposed to be a report on the world. In musculoskeletal medicine it is frequently something else: an assignment to a class, made on the basis of a finding whose relationship to the symptom was never established, which then shapes what the patient believes, what the surgeon offers, and what happens next. These three entries track a label from its invention to the randomised experiments showing what it does once spoken. The prior question — whether the named entity corresponds to anything the world divides that way — is theme ten's business.
8
Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder: A Preliminary Report
JBJS Am · 1972 · Neer CS 2nd · Uncontrolled case series
What it does: Proposes that chronic shoulder pain arises from mechanical impingement of the rotator cuff beneath the anterior acromion, and describes an operation to relieve it by removing the offending bone. There is no control group, no blinding, no comparator. Neer called it preliminary in the title.
Epistemological angle: This is the origin of a diagnostic category, an operation, and eventually an industry. A mechanism was proposed to explain an observation; a name was attached to the mechanism; and the name was thereafter used as though the mechanism had been demonstrated. Forty-six years later, the trials at entry
5 found that subacromial decompression does not outperform a placebo arthroscopy, and by then Lewis had already argued that the label encoded a causal story nobody had tested. The arc runs from hypothesis to diagnosis to industry to disconfirmation across half a century, and at no point in the chain did anyone go back and examine the first step.
My take: Neer wrote "preliminary" in the title and meant it. What happened afterwards happened downstream of him: a hypothesis became a diagnosis, the diagnosis licensed an operation, and the premise went unrechecked for forty-five years.
J Bone Joint Surg Am 1972;54(1):41–50 · PMID 5054450 · no DOI; pre-abstract era
9
Increased Absenteeism from Work After Detection and Labeling of Hypertensive Patients
NEJM · 1978 · Haynes RB, Sackett DL, Taylor DW, Gibson ES, Johnson AL · Industrial screening cohort with randomised compliance intervention
What it does: Screens steelworkers for hypertension and tracks absenteeism afterwards. Among those previously unaware they were hypertensive, absenteeism rose by 5.2 days per year — an 80% increase against a 9% rise in the general workforce over the same period. The rise was associated with becoming aware of the condition, and was unrelated to the severity of the hypertension, to whether treatment was started, or to whether blood pressure was subsequently controlled.
Epistemological angle: Everything the modern labelling trial at entry
10 demonstrates was shown here, in a different disease, forty-odd years earlier. The design isolates the label unusually cleanly: the physiological state was present before screening and unchanged by it, so the only new object in the world is the patient's knowledge of a category they have been placed in. That the effect was independent of severity and of treatment is what makes it an epistemological finding rather than a clinical one — the number on the sphygmomanometer did not predict the harm, the act of naming did. This is the entry that establishes the phenomenon is a property of diagnosis as such, not a quirk of musculoskeletal language.
My take: Sackett co-authored this, which is worth noticing given what he went on to found. The man most associated with evidence-based medicine published early evidence that the diagnostic act carries a cost the evidence base does not measure. I would not have predicted that, and I think it complicates the caricature of EBM as naively realist about diagnosis.
10
Diagnostic Labels for Rotator Cuff Disease Can Increase People's Perceived Need for Shoulder Surgery
JOSPT · 2021 · Zadro JR, O'Keeffe M, Ferreira GE, Haas R, Harris IA, Buchbinder R, Maher CG · Six-arm randomised trial, n=1308
What it does: Presents an identical clinical scenario to 1,308 people, randomising only the diagnostic label attached to it. Calling the presentation a "rotator cuff tear" rather than "bursitis" significantly raised the perceived need for surgery and for imaging.
Epistemological angle: The clinical content was held constant. The label added no information about the shoulder, and it changed behaviour anyway. That makes it an input rather than only a report — at minimum an input into what the patient wants done, and the interview study in this theme’s further reading gives reason to think it runs further than that. In reference-class terms the label is the assignment mechanism, and here the assignment is doing work that no fact about the joint supports. What the design shows directly is an effect on stated intentions; the step from intentions to the course of the illness is an inference this study invites rather than establishes.
My take: We suspected this. What we lacked was a randomised design with the clinical facts pinned down, which is what makes this the entry rather than the accumulated clinical impression. It seems to me a reason to think carefully about how we word reports, though I recognise that is easier said than done.
Also worth reading
O'Keeffe M, Ferreira GE, Harris IA, Darlow B, Buchbinder R et al. Effect of diagnostic labelling on management intentions for non-specific low back pain. Eur J Pain 2022;26(7):1532–1545 · PMID 35616226 · doi:10.1002/ejp.1981. Replicates entry 10 in the spine, with the effect largest in people already most exposed to overtreatment.
Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med 2013;11(6):527–534 · PMID 24218376 · doi:10.1370/afm.1518. Twenty-three interviews showing what a label does over years rather than what it does to a stated intention. Supplies the mechanism the vignette trials can only infer.