Are we losing the art of diagnosis?

I don’t think there’s any question that physical diagnosis has given way to diagnostic imaging. In some situations, this is not a bad thing. Take heart murmurs, for example. While in med school in the seventies, we’d get two eminent cardiologists to listen to the same patient’s murmur and often get two different diagnoses. Now, echo gives a far better evaluation. That being said, the great conjunction of managed care and defensive medicine nurtured the growth and development of the imaging reflex. Since time spent with the patient – history IS the cornerstone of diagnosis – is not reimbursed commensurate with importance, it’s much easier to reach for that referral pad and order a battery of tests than sit with a patient to glean all the info pertinent to the ailment. Additionally, secondary and sometimes tertiary tests are then ordered to substantiate findings and to rule out zebras should an untoward event occur. So in that sense, Greybeard is right.

Very few moments in my first two semesters of lecture were spent on the diagnostic process. One anatomy instructor did take several periods to do small exercises, and two physiology instructors took some time.

But, in the first year, it did not happen very often.

I’m just reporting my experience.

-j

Just so you know: When the younger generation gets together and talks about the “old school” we generally regard them as out of touch Luddites. I’m sure that you did the same.

I came to the conclusion that the art of medicine was lost after my mother spent 17 weeks in Kaiser and suffered immensely as a result of doctors with poor diagnostic skills, ignored histories and no physical examinations.

Despite a loud bruit in her left neck they all reported ‘no bruits’. Despite severe abdominal pain detected by the nurses, they refused to examine her as her Hb/Hct dropped and I finally made them stop ASA on an empty stomach and give her H2 blockers. Ultimately, she ended up with 8 units of pRBC during her stay. When she presented with a HR of 40 they immediately placed a PM and that procedure left her lethargic, on O2 and bedridden after she’d been awake, O2 free and transferring from bed and toilet to her motorized chair.

3 days later she had a red streak going down her left arm from the PM site and her white count varied from 30K to 13 K in the ensuing weeks with inept ID doctors hesitant to treat, despite positive BCs of staph epi and pleural effusions with a LLL infiltrate developed after the PM was placed. They sent in harp players and did very little for her. They gave up on her, refusing to listen to me, her physician child. She was discharged 7 times only to return within 24 hours with paroxysmal hypertension, refractory to clonidine, ntg, etc and finally was intubated for bilateral flash pulmonary edema.

The cardiologist and intensivist pulmonologist called it pneumonia, though she was fine prior to her 240 systolic accelerated hypertension. She was needlessly started on triple antibiotic therapy but that was stopped the next day when her lung xray showed clearing. Finally, they called me to ask what I wanted to do. After speaking with a brilliant colleague I hadn’t seen in 15 years, a nephrologist, I gave them a anti-hypertensive regimen that has worked now for 8 weeks. I remember the cardiologist saying he had to go along with the pulmonologist. I remember a doctor pulling her O2 to see how she would do despite a BNP of 1200.

4 hospitals, 50 doctors, lots of money. Only recently, after continued lethargy and sleeping an astute older doctor, ER doc, drew a TSH. It was 37. Her bradycardia was due to hypothyroidism, her severe reaction to opiates, fetanyl during the PM procedure was due to hypothyroidism, her foot ulcer and sacral ulcer, her severe leg pain, her flash pulmonary edema and her respiratory failure were all due to hypothyroidism.

My first question to them, in the very beginning was, what was her TSH. They said normal. It was not. I am angry and have lost any confidence in today’s doctors who refuse to speak with or examine their patients and pretend to make magical diagnosis that are more often than not incorrect. The art of medicine is gone, the ability to think lost and the new doctors little more than unskilled technicians.

If I hadn’t seen it I definitely would not believe it. Had I not been around, had some seasoned RNs not been around, my mother, who is doing much better and at home now, would be dead. No diagnositic acumen and no accountability. National health care will be a disaster for patients who cannot sue their HMOs. I am ashamed of what once was the medical profession.