To Listen to Doctors or Not

There are health situations that impact on mitzvah observance, such as fasting.  The halacha is that what the doctor says, goes.  This is adhered to by all Torah observant Jews, whether Litvish or Chassidish.

For example, there's the famous story about an epidemic in Lithuania and doctors said that nobody was allowed to fast. Most people were inclined to ignore this, since how could one eat on Yom Kippur? Realizing this, Rabbi Yisrael Salanter (founder of the Mussar movement) ate in shul in public on Yom Kippur.  Seeing him eat on Yom Kippur, the masses went home to eat too.

As for a Chassidic proponent, the Lubavitcher Rebbe wrote to someone, "I object to your not meticulously obeying the doctor’s orders, as “Permission was granted the healer to heal.”

By granting this permission, healing becomes a mitzva on the part of the healer, as well as a notable and great mitzvah on the part of the individual being healed, [i.e.,] “You shall scrupulously guard your health”; “It is part of the service of G‑d to insure that one’s body is healthy and whole.”

 

With that introduction, I came across yet another example of a woman who disobeyed doctors' orders and went on to have a child or children.  In this case, the woman died and was regarded admirably in her circles for having mesirus nefesh to bring children into the world. 

 

I understand that sometimes, doctors tell a woman not to have more children only because, in their view, no women should have children after the age of 35.  This is because it puts her into what the medical world considers a "high risk" category.  If the woman has no health problems, then a medical directive like this is not one we would regard as a mitzvah to obey, and if there are any concerns, they are discussed with a rav. 

 

But in a case where there is a specific reason for the doctor to be concerned about the mother's health, and she goes on to have children regardless, then even if she doesn't die as a result, is she a role model of mesirus nefesh for us? Or is she an example of someone who has transgressed the mitzvah of guarding her health?

Pills are Easier

A letter writer once irately wrote to a frum magazine, saying that of course, no parents want their children on ADD/ADHD medication unless it's absolutely warranted and all other options are explored.  She was quite adamant about that, though one could wonder how she knows that and whether she might just have projected her feelings onto others.

Mrs. B Grama writes a column for Hamodia's Inyan magazine.  She repudiated this view.  She writes:

"It has become quite common nowadays for us to open our weekly community magazines and find as many as a dozen ads for different therapy centers for children and adults, each one with a full staff of therapists ... Should we ooh and aah about it, or should we wonder why we are raising (or have ourselves become) a helpless, crippled generation that cannot seem to 'swim' on our own? Never before has there been such vast numbers of children who need outside help just to grow up (and vast numbers of parents who need assistance to raise them)."

She goes on to describe a woman who was diagnosed as suffering from "social anxiety" and thinks the woman is simply shy by nature.  Then she wrote about a man who was diagnosed with depression following his father's illness and watching his father suffer and fade away.  She wonders, isn't it normal to feel dejected under those circumstances? He needed support and encouragement from family and friends, not a medical diagnosis.

Worst example of all is about "Shaya's" mother who had a baby and whose father got a promotion so he came home later at night.  Shaya greatly missed all the times he used to speak to his parents after school every day.  "He became restless and unfocused in class and his behavior became problematic.  A psychologist was consulted and Shaya was put on medication to help improve his concentration and behavior."

When Mrs. Grama was consulted she asked the mother, "Wouldn't it be much simpler if you'd just make talking to and spending time with Shaya for about a half an hour at night your first priority?" To her shock, the mother said, "I know, but it's too hard; pills are easier."

So much for parents medicating their kids only as a last resort.

What We Eat

In a health column in a frum publication, written by a "certified Health Coach," Rivka Segal, the author says when she was studying to become a health coach, the school curriculum intentionally taught them conflicting dietary theories.  One week they learned about a carb-free, high protein diet and the next week they'd learn about a high carb diet.  Each course was taught by an expert in the field, often the founder of that diet.

Each time, the presentation was so convincing, that is, until the next class.  She says, "The purpose .. was to teach us that with diet and nutrition, there are no absolutes, and there is no one right way to eat."

It's "eating relativity" in which everyone can be right, and it's whatever works for you.

I find this troubling and I'm not sure it's true.  Granted, there can be differences between people in what they can and should eat and avoid, but aren't there general principles that apply to the majority of people? The Rambam thought so.  He even included his dietary guidelines in his Mishna Torah!

I found this anecdote she related quite interesting.  She spoke with someone whose daughter has Crohn's disease.  The mother said that a top doctor told her daughter not to discuss her condition with anyone.  Why? Not because of secrecy but because every patient's experience with Crohn's is different and what is helpful to one is not to another.  He felt that talking to others about their approach would be confusing and overwhelming and he encouraged her to figure out what works for her body.

She concludes by saying there are some general guidelines like we should avoid sugar, caffeine and processed food, and that we can all benefit from regular exercise, reducing stress, and drinking more water, but what about salt, coffee, eggs, butter, margarine, meat, whole milk and on and on? We read conflicting information on these items.  Are there no definitive answers?

Knee Surgery - Moral Issue

What should a doctor do when a patient complains of knee problems? What if the patient is obese or heavy enough that it is adversely affecting his knees?

Should a doctor say to an overweight patient - no elective knee surgery until you lose weight and seek other ways to help your knees?

Is it morally acceptable for a doctor to operate on someone, which entails anesthesia which has its dangers, various possible complications, and a recovery period, and of course, a hefty fee for the doctor, when the patient's weight is bearing down on his knees and causing the problem? Is that the build-a-hospital-under-the-bridge idea of Chelm in which they don't fix the bridge that is rickety and results in multiple accidents, but construct a hospital on site to deal with the injuries?

You Are What You Eat

In Torah Tavlin I read, the Rambam in Moreh Nevuchim says that the foods that we are not allowed to eat are not only spiritually impure, but are harmful to the body.  The Rashbam brings a proof for this from the Gemara in Shabbos 86b that gentiles who eat these foods have a different physical makeup than Jews.

Very interestingly, the Chasam Sofer (YD 158) says, based on this Gemara, that while non-Jewish doctors have ne'emanus (you can rely on them), nevertheless all their research is based on the biology of non-Jews, which is not like ours because of their different dietary habits.  Therefore, their medical conclusions do not necessarily apply to Jews!

 

Statistics and Us

Rabbi L. of Flatbush has a granddaughter in a coma (may she have a refuah shleima).  He reported that the doctor was asked what her prognosis is. 

The answer wasn't positive but the doctor added: You never know, with you people things are different.

***
It's one thing for us to hear that in a shiur or read it, and another thing when someone in the field, apparently not Jewish, says it!

Who We Heal

 219,464 Palestinian patients received medical treatment in Israeli hospitals during 2012 – 21,270 of them children.

News item:

While Hamas terrorists continued to hurl rockets and missiles at Israel, including the city of Haifa, Rambam Medical Center is now treating 20 Palestinians, including eight children from Gaza.

I don't recall reading that the Allies in World War II regularly treated Germans, Italians, and Japanese in their hospitals, children or otherwise, but Israel does treat those who seek to annihilate us.

News item:

"One of Israel’s top pediatric surgeons says he may have had enough. “…the situation has really become intolerable,” admits Dr. David Mishali, who heads the International Congenital Heart Center at Israel’s Sheba Medical Center in Tel Aviv.  And his role operating on, among others, ailing Palestinians, while his son is a schoolmate of one of those abducted, only highlights and exacerbates the tragic complexity of life in the Jewish state.

“This morning, I’m depressed. I’m really depressed to have to go in to work,” he replies, quietly.
“I’m fed up with it,” he says. “I’ve had it with being a ‘bleeding heart’ that always aids the needy,” he reveals.

Depressing indeed, to heal our enemies.  Chazal say, "Those who have mercy when they should be cruel, will be cruel when they should have mercy."  We see this in Israel time and again.

Help for Osteoporosis?

Yeshaya 66:14
"And you shall see, and your heart shall rejoice, and your bones shall bloom like grass ..."

Metzudas Dovid says that since worry and sadness dry up bones, the verse says at a time of simcha, the bones will be strengthened.

Do doctors recommend simcha and bitachon as ways to strengthen bones or only exercise and Vitamin D and calcium?

Let's Take Care of our Own!

So I see the headline, "Ten Year Old Palestinian Boy Saved by Israeli Doctors, Jewish Kidney Donor" and I'm disgusted.  Both by the fact that Israeli doctors treat our enemies (including those who attempt to kill us), and by the fact that a Jewish body was desecrated to achieve this.

It doesn't help that earlier this week there was a news item which stated, "PA President Mahmoud Abbas has made the resumption of peace talks with Israel conditional on the release of roughly 120 “heavy-duty” murderers."

A typical news item of this kinds states:

A Hizbullah guerilla who was moderately wounded in battle early Sunday morning was airlifted to an Israeli hospital for treatment.

Dr. Daniel Shani, executive director of the hospital in Nahariya, said the guerilla arrived in good condition. "He was brought to us by ambulance at around 5:30 a.m., and his condition was, generally speaking, good. He had an open wound in his right soldier," and other shrapnel wounds elsewhere on his body.

With regards to the type of treatment he was receiving, Dr. Shani insisted that it was no different than that of the average Israeli patient. "The ethnicity of the wounded is not important," he said. 
 
Oh really? Rather than being the "am chacham v'navon" (the wise and discerning nation), we make fools of ourselves and put ourselves in danger, solely to garner praise and admiration from our enemies which are not forthcoming anyway.  Let the Arabs take care of their own people in their own hospitals with their own doctors!

There shouldn't be the slightest chance of a Jew being put in danger in order to help our sworn enemies!

"He who has compassion when he should be cruel, will be cruel when he should have compassion"!

As one person put it, "I'm waiting to see the headline: Arab doctor treats Jewish boy." Who is guaranteeing that this child won't grow up as brainwashed as the rest of them and seek to harm those who saved his life?

 

Upping the Odds for a Miracle

A letter that I wrote to a frum publication:

I'd like to share with your readers what it says about prenatal sonograms in the book Aleinu L'Shabei'ach (Devarim, p. 242) by Rabbi Yitzchok Zilberstein. After a patient refused to have an ultrasound done, with Rabbi Chaim Kanievsky's support, a doctor asked R' Zilberstein to explain this to him. He asked his brother-in-law, R' Kanievsky who said that if there are no specific medical problems with either the woman or the fetus, it is preferable for her not to do a routine sonogram. As long as no problem has been diagnosed, prayer is more beneficial. If, however, a woman has a sonogram done and it shows a defect in the fetus, it will require an open miracle to heal the baby and not everyone is worthy of a miracle.

R' Zilberstein brings support to this position from the miracles related about Elisha and the Shunamite woman with the oil and later with her son, in which the miracles needed to be performed discreetly. Hashem wants miracles to be done in as inconspicuous a manner as possible. A blessing from a sage and prayer are more effective when an illness or defect have not been discovered and a big miracle need not be performed.

R' Zilberstein said he heard in the name of the Klausenberger Rebbe zt'l that a person should go to a sage for him to pray before he goes to the doctor, because once the doctor says there is a serious problem, it is much more difficult for the sage to reverse it.

R' Zilberstein adds that many times, women have the routine sonogram which reveals a possibility of a problem and this causes the woman to be extremely anxious and fearful, especially when many defects are incurable. Doctors often recommend the termination of the pregnancy, which is forbidden. All of the anguish suffered by the mothers is therefore pointless, he says, since there is nothing they can do about the defect and there is a good chance the baby will be fine. It is better not to take these tests since Hashem created the world in such a way that a woman should not know what is in her womb, as Shlomo Ha'Melech says in Koheles 11:5.

I have read numerous stories of women who were given dire news upon taking a sonogram and were pressured to terminate the pregnancy. These stories ended with a healthy child. Were the doctors wrong or did a miracle occur? We don't know. What we do know is that those reading the sonograms don't even get the gender right 100% of the time, or the size of the baby. If sonograms are about saving even one life, as one letter writer wrote, thought should be given to all those lives that are ended, r'l, because of routine sonograms. Likewise, thought should be given to the effects of prolonged and extreme anxiety on the expectant mother and the fetus.

Fallible Experts

I keep on bumping into articles and true stories in books about experts who made pronouncements and were proven wrong.  Examples include those who said a four minute mile is impossible (as I posted recently), doctors who said a baby has no chance of survival (she went on to marry and have children), and doctors who said an autistic child would never talk and he went on to become a professor.

Experts share their expertise on politics, the economy, world events and the weather and are not infallible.

What is their track record? Are they way more right than wrong? I don't know.  I know that we revere experts and take their word for whatever is their topic.  Or we take their word when it coincides with our beliefs.

Perhaps G-d makes them wrong some of the time in order to give us a chance to bring Him into the picture.  If experts were right 100% of the time, it would make it almost impossible to have hope, to believe in a different outcome.  Being wrong some of the time ought to make the experts humble.  At least, it should reinforce our belief that G-d is in control.

Medical Treatment that Kills

Rabbi Moshe Sherer a'h, was chairman of Agudath Israel of America.  There is a 600+ page biography about him out of which I read a few hundred pages.  He was a dynamic, driven person who could have made millions if he ran a company but devoted himself to the welfare of Klal Yisrael. 

How shocked I was to read that he contracted acute leukemia as a result of the chemotherapy he had taken for lymphoma (which happens in 8% of cases)! That medication is accompanied by unpleasant side effects, is one thing; that the medication causes a virulent disease when being applied to cure a virulent disease, is outrageous.  Similar to one of the side effects of antidepressants being suicidal thoughts.  May Hashem spare us such cures and keep us well.

What Doctors Say

A mother said, "My daughter was valedictorian recently. I'm proud to say it because she had a very hard beginning, and spent many weeks in an ICU after she was born. The neonatologist said she will never be in a regular classroom."


Time and again, I read stories in which doctors make dire pronouncements and are proven wrong.  In Judaism we have the principle: doctors are permitted to heal (with Hashem's help).  They have no right to make pronouncements about the future.


They make dire prognostications in the name of honesty and enabling parents or the patient to be prepared, but since they aren't prophets and are sometimes (often?) wrong, what they say is cruel and counter-productive.  As authority figures, what they say carries a lot of weight and it can be very hard to be optimistic and have bitachon in the face of bad news from a doctor.


How many parents have gone through months of agony because a doctor said their unborn child would not be normal, would be deformed, until to have a healthy child be born? I'm always left wondering whether the doctor interpreted the information correctly and the couple's prayers changed things, or the doctor was mistaken from the get-go.  I don't know, but I have read numerous stories in which this happened.  True, the doctor's negative expectation may have been the impetus for lots of prayer and good deeds, but that did not give him the right to scare people who won't abort and can't do anything about the situation.


It would be helpful if someone collected many of these stories, verifying the information, i.e. what the doctor said and what actually happened, in categories like: pregnancy, preemies, illnesses, comas, what faculties and abilities patients were told they could and could not regain, and how many years they were told they would live.  It would be a great resource in bolstering our faith in the Rofei chol basar.

Sybil Exposed

I did not read Sybil but I am reading Sybil Exposed.  Sybil was a book published in 1973 that went on to become a bestseller and a movie.  It was presented as the true story of a woman treated for multiple personality disorder who had been so horribly abused by her mother that she became a psychiatric case.  The book described grotesque rated R scenes that had the public enthralled.  Not surprisingly, huge numbers of people were diagnosed as having a multiple personality disorder after the book became a hit (like anorexia became a "fad diagnosis" in Hong Kong after it was marketed there, see my post "Crazy Like Us"  click here to read post

The lives of three women are intertwined: the patient, her doctor, and the author of Sybil.  The author of Sybil Exposed shows how the patient's illness wasn't an illness, how her treatment was a sham, and how the fictional story Sybil came to be written and presented as the truth. 

As much as the book is an expose of the book Sybil, it is an expose of the quackery of the psychiatric profession.  As anybody who has read previous posts (labels: psychiatry and mental illness) on this blog have seen, I am not impressed by the pseudo-medical specialty of psychiatry.  The so-called treatments given by the doctor in this case as well as her colleagues back in the 50's till the present day, are a horror.  Forget about "first do no harm."  That is far from their guiding principle.  When will the public finally figure out that the emperor has no clothes? That the psychiatric/mental health profession in cahoots with the drug companies are making us into a nation of drugged, incompetent, invalids?

An Extra Kidney?

The frum media has had many heartwarming stories lately, about people donating kidneys to those in need, strangers to the donor.  Poskim have ruled that it is permissible to do this.

What I wonder about is the comment, often made by those promoting kidney donations, that perhaps this is the reason why Hashem gave us an "extra" kidney, so we could donate it.  This is predicated on the view that we don't need two kidneys and that we can function perfectly well with one.

This pronouncement does not sit well with me.  Is this really the case, that for millenia, billions of people were given two kidneys by Hashem, so that in our generation, a few people can donate a kidney? It is reminiscent of the medical wisdom of yesteryear in which tonsils and the appendix were considered superfluous and were frequently surgically removed without a compelling reason to do so. 

I'm sure it's true that as of now, with the medical knowledge we have today, it looks as though a person can manage just fine with one kidney, and since a person in dire need of a kidney is in a state of pikuach nefesh, poskim have ruled that a person can donate a kidney.  However, to say that Hashem created us with an extra, unnecessary organ? I'm not convinced.

Unhinged: The Trouble With Psychiatry - A Doctor's Revelations about a Profession in Crisis

I read a fascinating book about psychiatry written by a practicing psychiatrist who, as the book flap says, exposes deeply disturbing problems plaguing his profession.  He writes about how psychiatry is mostly about prescribing drugs these days, with all the troubling consequences that entails, and has largely forsaken talk therapy.  This is because they will earn far less doing therapy than by prescribing drugs.  He says if he did therapy, he could see one patient an hour and he would earn about $70/hour.  He typically saw three patients an hour, for years, and he made $180 an hour (factor in expenses and he made closer to $130 an hour).

He writes about how they treat symptoms after determining that the patient exhibits an arbitrary number of signs that match a supposed disorder.  They spend fifteen minutes on a patient and don't bother finding out about the patient's life.  He shows how DSM diagnoses are not particulary scientific, and tells us that the number of possible diagnoses has increased from 182 to 263.  Unbelievably, a committee votes on deleting what is considered old-fashioned disorders and voting in newfangled disorders.

What he says backs up many things I have believed about the profession but I am no authority; he is! So when I read that a practicing psychiatrist says there is no proof to the chemical imbalance theory of depression, I say wow! I have read numerous articles over the years in frum and not Jewish media that speak about a chemical imbalance with the same confidence we reserve for the sun rising in the morning!

He says the scientific literature contains thousands of papers proposing neurobiological theories to explain PTSD, depression, bipolar disorder, schizophrenia and other psychiatric disorders but these theories remain unproven! He says, "the shocking truth is that psychiatry has yet to develop a convincing explanation for the pathophysiology of any illness at all."

Even as I was amazed by the honesty of the author in showing the major flaws of his profession, I was shocked that he still goes through the motions.  How pathetic to drug someone when their problem is clearly loneliness or unhappiness with their job.  As a colleague of his put it, "Most of the people I see have misery and unhappiness rather than major depression.  They are miserable because of problems in relationships or difficulties coping with their life's circumstances."  She doesn't drug them.  She makes half of what a full-time psychiatrist in private practice makes because she does talk therapy instead.

There is a chapter on how drug companies market their drugs to psychiatrists.  Oh boy ... it's so crooked that the author, who started out innocently working as a paid drug endorser for one of these drug companies, stopped working for them despite the great pay ($30,000 - and this is aside from his private practice) and perks because he realized he was selling his soul and was no longer willing to do so.

It's a readable book for the layman and I highly recommend it.  Time that more people realized that "the emperor has no clothes."  Our health, mental and otherwise, is at stake!

Psychiatry part 3

In Mishpacha magazine's supplement "Calligraphy" from Pesach (which usually has fiction but this time had non-fiction), there is a very disturbing story about a third grader in Israel who was doing wonderfully in school until he began speaking less and less and was diagnosed by a pediatrician with selective mutism (which does not explain anything, just describes the fact that the child isn't talking).

He began to withdraw socially and then stopped speaking altogether. A psychologist had him draw on a paper, asked the parents whether the child had experienced any trauma, and when they said they no, the psychologist said she thought he was reacting to a severe trauma or was psychotic and to bring him back in a week.

Rather than explore what might be bothering the child who had been 100% normal till then, a week later the same psychologist recommended that they take him to a psychiatrist because she decided that his condition was dire.

Based on this, they actually picked up and moved the family to Yerushalayim! (yes, they asked a shaila and sorry to say, the psychologist's opinion was adhered to like it was the word of G-d).

Unbelievably, this poor child was enrolled in a special needs school. Interestingly, he still sang zemiros at the Shabbos table but otherwise, he was doing worse.

They took him to a pediatric psychiatrist. Their child was 10 and a half and the change had begun three months before. Without interacting with the child at all, this rasha of a doctor declared that the boy was either experiencing clinical depression or psychosis and he wrote out a prescription.

Around the third visit, the child went over and touched the fax machine and this doctor yelled at him, stood up and forcefully waved his hand and said, "Get away from there! You're psychotic, yes you're psychotic!" And he wrote out another prescription.

This is a pediatric psychiatrist!? Why, oh why, did this evil person specialize in working with children when he hates them? And by what did he write out a prescription without thoroughly examining the child?

The story goes on. They administer drug and after drug to the child who gets worse and worse.  He had terrible side effects from the drugs, was diagnosed with schizophrenia, was confined in a psychiatric hospital, was severely beaten and abused by the Arab driver of the van that took him to his institution, and then a particular drug was credited for helping him get back to normal.

The parents did what they thought was best. I feel sad for them and the miserable experience they had, uprooting their family and everything that happened, but it needs to be said: Nobody bothered trying to find out what made a previously normal 10 year old withdraw. These medical doctors are trained to diagnose pathology.  Mental illness is nebulous, usually with no physical evidence of a physiological problem and as in the case with the "Girl in the Green Sweater" and the woman in the "True Healing" post, drugs and mental illness labels were not what was needed.  A person reaching out in kindness with the way to the person's heart is what was needed.

This reminds me of an article I read about a year ago about a man who came to the US to collect tzedaka so he could pay for a wedding.  Once in America he was unable to get himself out of bed.  A friend took him to a psychiatrist and you'll never guess how the MD treated him .... Are you ready? Have you guessed? Yes! He wrote a prescription for an anti-depressant!

Now tell me, if the doctor had written out a hefty check for the person, or if the fundraiser had unexpectedly won the lottery, would he be depressed? Nope.  Would he need drugs? Nope. So why are we, as a society, allowing our fears and sadness to be treated with drugs?

Psychiatry part 2

I recently read another two things (in addition to my "True Healing" post, two posts ago) that have reinforced my strong feelings about psychiatry. 

I am almost finished reading "The Girl in the Green Sweater" by Krystyna Chiger about how she survived the Holocaust at age 7 by hiding in the sewers beneath the city of Lvov for fourteen months.  After many months underground and enduring horrific living conditions (swarming rats, for one thing) the usually cheerful girl became silent, sullen and sad.  She did not feel like eating, talking or doing anything.  It's what a psychiatrist would diagnose as childhood depression.

Her mother was desperate about her, thinking her temperament was changed forever and so she told the Polish man who was their protector about her concern.  The Pole led her through the pipes and said, "Let me show you something."  She crawled through and then climbed a ladder which led to an opening to the street where she could see sunlight through the grate.  It was the first sunshine she had seen in over a year.  She heard children playing outside.

He said to her, "You have to be strong, little one.  In just a few days, you will be up there playing with the other children.  You will smell the same flowers."

And she writes "And in this way I became whole again," thanks to him.

What would a psychiatrist have done for her? Without a doubt, reached for his prescription pad and drugged her.

(more in the next post)

True Healing

Rachel Naomi Remen is a medical doctor who opened a practice where she speaks to seriously ill and suffering people and through her wisdom and caring guides them towards emotional healing.  In "Kitchen Table Wisdom" she describes a woman who was intensely grieving the loss of the love of her life.  Her grief was so acute, way beyond the norm, that a psychiatrist diagnosed her as having "reactive depression" and he treated her with progressively more powerful antidepressants which did not work.

She had several sessions with Dr. Remen in which she opened up about her pain which enabled her to move forward.

That's the chapter in a nutshell.  I won't repeat what the woman's thought process was and how Dr. Remen's suggestions broke through her numbness.  What outraged me about this episode is how the medical community, psychiatrists in particular, seek to label symptoms and drug us rather than heal us.  What the grief-stricken woman needed was not drugs to mask her symptoms (and give her numerous side effects to suffer from) but someone to truly listen to her and show her that she had the choice to move on.

We have numerous statements in Torah sources about the mind-body connection and yet we too, in the frum world, have fallen prey to drugging symptoms in children and adults.  We need wise people amongst us whom we can turn to; people who don't view coping mechanisms as medical illnesses; people who can listen and provide wise guidance within a Torah framework to those who are suffering; people who will talk about emuna and bitachon and simcha rather than diagnose syndromes and disorders.