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,
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
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.