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                        JeffNEWS, August 16, 1994
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Franz Kafka Wrote of Issues of Diagnosis 
That Will Carry Medicine Into the 21st Century
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By Steven Mandel, MD
   Clinical Associate Professor of Neurology and 
   Clinical Assistant Professor of Pediatrics

Known especially for The Trial, The Castle and The Metamorphosis, the 
Czech author Franz Kafka is widely regarded for having a creative vision 
years ahead of his time. In his work, he prophetically foresaw issues of 
modern bureacuracy, authoritarianism and the helplessness of the individual 
caught in society's web.

In a lesser known story adapted as a film, "The Insurance Salesman," 
Kafka also prophesized how critical the issue of diagnosis will be to 
medicine in the years to come.

In the story, a person suffering from a rash waits in line at  a clinic 
for days. Finally the person is asked "When did your injury take place?" 
The potential patient replies, "What injury? I have a rash. It's related to 
my job." And you know what's coming. The response is, "You shouldn't be 
here." 

Wrong line, wrong "official" diagnosis. Kafka probably "heard" the 
approaching footsteps of a modern medical field like occupational 
neurology, which today would have correctly classified his potential 
patient.

The story is telling for modern medicine because the importance of 
correct diagnosis is taking on added significance, framed in legal and 
social contexts as well as medical. For example, 75 years later, our more 
precise society offers five legally standard definitions for these five 
terms: impairment, disability, handicap, accident, injury. Doctors and 
other healthcare professionals need to know them.

This knowledge will be important to medicine in the 21st century because 
doctors will have to learn how to better evaluate their patients in regard 
to their occupational history. This is doubly important because of the 
impact of the American Disability Act, which allows that a person's 
impairment does not preclude the person from performing the essential 
functions of a job.  

The role of pain in diagnosis is especially key. We know that 62 percent 
of patients report symptoms of pain - very nearly two of every three people 
who see a doctor. In patients suffering acute pain, every effort is made to 
identify a physical cause. For example, a patient having chest pain, 
thought to be caused by a heart attack, actually turns out to have a 
herniated disc in the mid-back region. For patients who suffer chronic 
pain, causes are much harder to identify and so can make diagnosis 
problematic. 	

Jefferson's approach to diagnosing and treating pain is clearly 
multidisciplinary, with patients being examined and evaluated by, as 
appropriate, a psychiatrist, psychologist, neurologist, rehabilitation 
physician, vascular surgeon, neurosurgeon, anesthesiologist and other pain 
specialists.

When you add to pain diagnosis and treatment, two other modern medical 
areas - occupational neurology and minor head trauma - you have a group of 
medical factors fueled by several major social forces: increasingly 
sophisticated medical techniques, stress and diversity of modern life and 
legal scrutiny as exemplifed by the American Disability Act.

All these seem particularly Kafkesque issues that he probably would have 
related to in both their sum and part. It's more important than ever that 
diagnosing physicians make sure their patients wind up in the right line. 
Kafka would concur.


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