The physician as detective


Category : General, Medical Rants

Frequent readers may remember that I love mysteries. I believe that accounts for my love of morning report and CPCs. Many general internists share this love for a genre which closely parallels our field.

For those with access – White coats and fingerprints: diagnostic reasoning in medicine and investigative methods of fictional detectives

Current trends toward routine mass use of sophisticated diagnostic tools is killing off the science and art of clinical reasoning. An ideal clinician would present a harmonic fusion of almost all the investigative methods of fictional detectives and avoid slavish adherence to protocols and procedures

Our underlying premise is that the current trend towards mass use of sophisticated diagnostic tools in routine practice—accompanied by a blind faith in technology and predefined diagnostic algorithms—is threatening to kill off the science and art of clinical reasoning. Besides burning a lot of public and private money to make diagnostic work rather superficial, doctors also risk losing the intellectual pleasure that comes from careful diagnostic reasoning.

Clinical analogies with detective fiction generally revolve around Sherlock Holmes.1 2 However, like medicine, detective fiction has subspecialties and intellectual trends.3 A rapid overview of the analogies between diagnostic reasoning and the investigative strategies found in detective literature may provide us with some clues on how to confront the problems posed by the burgeoning number of available technologies.

I disagree with the initial assessment because the authors leave out an important factor. No diagnostic test helps if we do not know to order the test. The intellectual challenge of internal medicine in 2005 remains active. Patients come in with vague complaints, which we must sort through using history and physical clues. These clues help us develop a differential diagnosis (a list of possibilities) which we can rank as to likelihood. Then, and only then, should we use technology to sort through the possibilities.

We could take everyone who comes in with vague complaints and order a “man scan” (the resident’s slang for total body CT scanning). But this strategy would yield too many red herrings, and still not find the underlying problem very often.

After the somewhat depressing introduction, the authors redeem themselves by discussing in beautiful terms the type of reasoning that various famous detectives use. Their final paragraph is classic!

An ideal clinician could be said to present a harmonic fusion of almost all the investigative models outlined above—a rare event. If one investigative quality marks out the mature clinician it is the ability to spot possible inconsistencies among the clinical, instrumental, and laboratory examinations, considering not only what is present but also what is missing. This requires skills in observation and “deduction,” handling of knowledge, pattern recognition, and the astuteness that comes from years of experience. For well honed clinicians, the clinical part of the diagnostic investigation is not just a question of medical history and physical examination but rather the capacity to establish links among various physical and laboratory or instrumental findings with an eye to both the consistencies and inconsistencies. In this context, simple examinations really do have the same value as the more complex and expensive ones.

Bravo! Bravo!! (here db stands for an ovation)

free viagra
buy viagra online
generic viagra
how does viagra work
cheap viagra
buy viagra
buy viagra online inurl
viagra 6 free samples
viagra online
viagra for women
viagra side effects
female viagra
natural viagra
online viagra
cheapest viagra prices
herbal viagra
alternative to viagra
buy generic viagra
purchase viagra online
free viagra without prescription
viagra attorneys
free viagra samples before buying
buy generic viagra cheap
viagra uk
generic viagra online
try viagra for free
generic viagra from india
fda approves viagra
free viagra sample
what is better viagra or levitra
discount generic viagra online
viagra cialis levitra
viagra dosage
viagra cheap
viagra on line
best price for viagra
free sample pack of viagra
viagra generic
viagra without prescription
discount viagra
gay viagra
mail order viagra
viagra inurl
generic viagra online paypal
generic viagra overnight
generic viagra online pharmacy
generic viagra uk
buy cheap viagra online uk
suppliers of viagra
how long does viagra last
viagra sex
generic viagra soft tabs
generic viagra 100mg
buy viagra onli
generic viagra online without prescription
viagra energy drink
cheapest uk supplier viagra
viagra cialis
generic viagra safe
viagra professional
viagra sales
viagra free trial pack
viagra lawyers
over the counter viagra
best price for generic viagra
viagra jokes
buying viagra
viagra samples
viagra sample
generic cialis
cheapest cialis
buy cialis online
buying generic cialis
cialis for order
what are the side effects of cialis
buy generic cialis
what is the generic name for cialis
cheap cialis
cialis online
buy cialis
cialis side effects
how long does cialis last
cialis forum
cialis lawyer ohio
cialis attorneys
cialis attorney columbus
cialis injury lawyer ohio
cialis injury attorney ohio
cialis injury lawyer columbus
prices cialis
cialis lawyers
viagra cialis levitra
cialis lawyer columbus
online generic cialis
daily cialis
cialis injury attorney columbus
cialis attorney ohio
cialis cost
cialis professional
cialis super active
how does cialis work
what does cialis look like
cialis drug
viagra cialis
cialis to buy new zealand
cialis without prescription
free cialis
cialis soft tabs
discount cialis
cialis generic
generic cialis from india
cheap cialis sale online
cialis daily
cialis reviews
cialis generico
how can i take cialis
cheap cialis si
cialis vs viagra
generic levitra
levitra attorneys
what is better viagra or levitra
viagra cialis levitra
levitra side effects
buy levitra
levitra online
levitra dangers
how does levitra work
levitra lawyers
what is the difference between levitra and viagra
levitra versus viagra
which works better viagra or levitra
buy levitra and overnight shipping
levitra vs viagra
canidan pharmacies levitra
how long does levitra last
viagra cialis levitra
levitra acheter
comprare levitra
levitra ohne rezept
levitra 20mg
levitra senza ricetta
cheapest generic levitra
levitra compra
cheap levitra
levitra overnight
levitra generika
levitra kaufen

Comments (1)

Another quote from the article: “A juridical approach to guidelines can also lead the clinician to systematically abandon pathophysiological and clinical reasoning in favour of a purely defensive form of medicine owing to the fear of leaving space for the creativity of lawyers.”

One might assume this was written by an American doctor. It was not; it was written by the principal author, a cardiologist in Northern Italy. Food for thought.

Post a comment