Barrett L. Dorko, P.T.

In the classic fantasy A Wizard of Earthsea by Ursula K. LeGuin (Bantam 1968) there is described a world where everything including the people have two names; a use name, and a true name.

The use names are known to everybody and are simply a part of the common language. The true names are unrelated phonetically to those commonly used and are essentially secret. This is because uttering them gives the speaker power over that which is truly named. For that reason, the people in Earthsea guard their true names from others. Those who learn the true names become the wizards in this land.

There are two distinct categories of diagnoses in medicine; nominal and essential. Nominal diagnoses are those which name a disorder without necessarily providing any clue about which tissues are involved or in what way. Lupus Erythematosus is a classic example. The name is derived from the reddening of the skin of the face that is reminiscent of a "wolfen" appearance.

Essential diagnoses describe the tissue or system involved and the nature of its dysfunction. Unlike "lupus" they naturally imply what kind of care or treatment will lead to improvement or resolution. A diagnoses of "fractured humeral head" brings immediately to mind appropriate modalities of care.

Perhaps you can see where I'm going with this - nominal and essential diagnoses are precisely parallel to the use and true names of the objects and people in LeGuin's fantasy. And we only have power over those conditions that are essentially (that is, truly) diagnosed.

A dramatic example of movement from nominal to essential diagnoses has been seen in gastroenterology during the past decade. In 1983, Barry Marshall of Australia proposed that peptic ulcers were not solely due to excess acidic production primarily related to stress. He had discovered an infectious etiology and resolved long-standing ulcers permanently with antibiotic therapy. By finally naming the condition with an essential diagnosis, he had become as powerful as any wizard of Earthsea reciting an effective incantation.

In physical therapy there are a number of diagnoses that nobody likes to see on the referral. They contain words that are useful but essentially untrue. They are useful in the sense that they place the patient within a category that may rule out many things, and give the patient at least a temporary sense that somebody might know how to treat them.

But they soon find that diagnoses like "backache," "cervical strain," and "fibromyalgia" carry no power, and that unless they get a new name for their problem (hopefully a true one) they will be subject to a variety of treatments. These treatments usually follow a path of decreasing favor in their therapist's mind. It's a kind of "maybe this will help" attitude.

It seems to me that the time and expertise available to our community might often help us learn the true names of our patient's problems, names that transform our care and increase the power of our presence.

Managing to become a wizard probably begins with our recognition of what names don't help our vision of the patient's path toward recovery, and then searching for the true ones.