The practice of medicine has never been an exact science. While medical trials and technological advances have significantly helped further the practice of medicine, there is still a lot we don’t know. All doctors must be comfortable with a degree of uncertainty when treating patients. There are a variety of diseases that we can diagnose with certainty, however there are a lot of diagnoses that we give without a confirmatory test to ensure that we are right. These are called diagnoses of exclusion.  

The diagnosis of exclusion is a concept that doctors use every day. However, I believe it is often misunderstood by patients and causes confusion. In order to be a Wise Patient, you need to know what we mean when we are considering a diagnosis of exclusion. 

A diagnosis of exclusion (DOE) is a diagnosis that we give a patient whenever we have reasonably ruled out everything else. It comes after a process of elimination. DOEs do not have any confirmatory tests such as a lab or imaging study, so we cannot know for sure that you have it. Only after we have ruled out everything else on the list of likely differential diagnoses should we give you the diagnosis. We use, instead, diagnostic criteria that gives us more certainty that you have this DOE.

A good example of a DOE is irritable bowel syndrome (IBS). IBS is a syndrome that causes alternating diarrhea and constipation and abdominal cramping. It is usually related to stress and/or certain foods. Your lab tests and imaging results and colonoscopy should all be normal when you have IBS. The diagnosis should only be given once the rest of the work up for the abdominal symptoms has turned up negative. Follow this link below to a calculator that we use to evaluate your symptoms for the diagnostic criteria of IBS: https://www.mdcalc.com/rome-iv-diagnostic-criteria-irritable-bowel-syndrome-ibs

Some other examples of DOEs include:

– Fibromyalgia

– Muscle Strains and spasms

– Anxiety

– Depression

– Idiopathic Neuropathy

I have found that patients have a tendency to feel uneasy about being given a diagnosis of exclusion. The biggest reason for that uneasy feeling is the lack of a confirmatory test to make sure the diagnosis is correct. Some people leave the office fearing that something may have been missed. I think this feeling is understandable, and I try to alleviate that fear the best I can. If I diagnose a patient with a diagnosis of exclusion, then that means I am confident we have ruled out all of the emergent and/or dangerous diagnoses. Once the life-threatening things are excluded, then I feel like we have more time to work with a DOE. We can then try some diet changes or medications to see if they help. If they do, then I am even more confident that we made the right call. And if things aren’t helping, then we can always revisit the differential diagnosis to see if your symptoms need to be re-evaluated.  

Being a medical mystery can be stressful, but the Wise Patient understands that there is not a test for everything. With this knowledge you can work with a doctor you trust to navigate a mysterious diagnosis and to get a treatment plan that works for you.