“Badness” is a spectrum


Here is a question I get asked all the time by patients: “Is that bad?”

This is different than the similar, more appropriate question “Is it bad,” which is usually asked after being given a specific diagnosis.  For example, after a colonoscopy where a large polyp was discovered and removed I will tell the patient about the findings.  He may ask “is it bad?” The answer is usually “No, the polyp could become something ‘bad’ but now it has been removed so it’s nothing to worry about.  I will call you when the pathology results come back from the lab.”

“Is it bad” is an honest question.  “Is that bad” is usually also an honest question, but one that is much more difficult to answer.  Patients usually ask “is that bad” without actually having a diagnosis yet.  At the end of our visit I try to summarize the pertinent issues and I will usually list a few of the possible diagnoses that may explain the symptoms.  Then we will come up with a plan to test for these diagnoses. I might say “This is probably irritable bowel syndrome, however some of the symptoms could be consistent with Crohn’s disease or ulcerative colitis.  We need to do further testing to figure out which one it is.”

A very common response is: “Oh, Crohn’s disease! Is that bad?” I always find that question difficult to answer.  The question is asked in a way where a “yes” or “no” answer seems appropriate, like “Is your car red?” In a literal interpretation, the answer to “is that bad” should therefore always be “yes” if we are comparing the possible malady to the alternative situation of not having such a problem.  It is always better not to have Crohn’s disease than to have it, right?

I think what people are getting at with this question is more like “If I have that condition, is it something treatable or is my life going to change forever for the worse?” Maybe this question is more accurate, but still not really a question that can easily be answered.  To use our example, Crohn’s disease (like most things) has a spectrum of severity ranging from mild inflammation easily controlled with a once-a-day pill, to severe complications requiring major surgery and lifelong combinations of potent immune suppressing drugs with continued symptoms despite all of this.  There is no “yes or no” answer, especially when I am not even sure that the patient has this disease.  Do I need to go into every possible issue related to Crohn’s disease, or do I wait to actually make the diagnosis first and then have that discussion?

The logical answer is to wait to make a diagnosis before discussing theoretical issues, however the “Is that bad?” question makes it difficult to sidestep a more time-consuming, anxiety-provoking, and more than often, irrelevant conversation about a disease that the patient may not even have.  Badness is a spectrum: no disease is “good” to have.

"Is that bad?"

“Is that bad?”

At the end of the day, when these issues come up I fault myself.  Perhaps I am giving out too much confusing information too early in the process.  I want to inform and educate patients about some of the likely possibilities, but maybe I am just creating chaos by talking too much about theoretical issues instead of concrete issues like ‘what is the next step.’ I am a fan of transparency in decision making, but the other edge of that sword is fielding a lot of questions; most of these questions ultimately proving to be irrelevant once an alternative diagnosis is made.

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