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Reply from the Authors: We are gratified by Dr. Benditt's interested astonishment and by his ill-tempered concern with diagnostic validity and reliability. We pointed out that the only diagnostic gold standard (his "diagnosis is right") is rarely achieved: direct observation of the spontaneous syncopal event. In the real clinical world, the challenge is to attain a silver standard, a reasonably probable working diagnosis based on detailed history of symptoms including witness reports, risk factors of past history, and current interval examination. For example, no extensive study is needed for the report of a single syncopal episode when a woman's hand is smashed by a car door or when she is roused from bed to be informed that her child was killed. Specific suspicion is warranted by history of provocative medication, current examination evidence of postural hypotension, or by symptoms similar to those of the "fainting" complaint elicited by voluntary hyperventilation. On the other hand, "fainting" when not standing suggests something other than vasovagal syncope. Our emphasis on the working diagnosis is the implicit indication for close follow-up management and diagnostic challenge by a well-informed and responsible physician.
Although Benditt claims absolute security in his own right diagnosis, Kapoor,2 the authority whom he cites, has a more realistic and diffident diagnostic style [italics ours]:
In those patients in whom a diagnosis can be assigned, the history and physical examination identify a potential cause in 49% to 85%. Furthermore in 8% of additional patients, history and physical examination are suggestive of causes that need confirmation by specific tests.... Diagnosis of arrhythmias as a cause of syncope is problematic because symptomatic correlation during electrocardiographic monitoring is rarely found (approximately 4%), and as a result, there is no uniform agreement on diagnostic criteria for abnormalities. Similar problems exist in the use of …
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