A dermatologist blogger writes:

There is another way to look at this. Take a hypothetical analogy: lets say I invented two diagnostic machines – one is inexpensive but low sensitivity and specificity the other is expensive but high sensitivity and specificity. Which would you choose to help your patient?

Isn’t that analogous to using clinical diagnostic tests or choosing to use expensive studies?

You could diagnose an acute MI from Hx and physicial, or use diagnostic testing. Which would you choose?

This misses the point! The art of diagnosis does not exclude science. Diagnostic artists tests to either make diagnoses or exclude reasonable possibilities. What I see too often is a lack of thought prior to ordering tests. What I see too often are poor history and physical examinations taking the diagnostic odyssey in the wrong direction.

Perhaps an example would help. Several years ago, at about this time of the year, a 50 something veteran came to the hospital. The intern presented him and focused on the chief complaint – a vague, poorly defined chest pain. He ordered a stress MIBI for that day.

I take the team to the bedside and ask the patient what is bothering him. He complains primarily of right upper quadrant pain. I ask about the chest pain, and he dismisses it – just happened yesterday and it is gone. I ask more about the RUQ pain and he gives a month history of progressively worsening pain.

So I listen to his heart and lungs which are normal and exam his abdomen. In fact he has RUQ pain with a positive Murphy’s sign. So of course I suggest that we obtain a RUQ ultrasound.

The story is a long one, but here is the abridged edition. The radiologist saw a liver mass on ultrasound. We next did a CT scan and the radiologist told us that the patient had an abscess. On day 4 he developed a fever – we had already started appropriate antibiotics. Eventually he had surgery to drain his abscess – the organism was methicillin sensitive staph aureus.

The art here was listening to the patient’s story. I avoided the biggest error in decision making – premature closure. The diagnosis was made with imaging studies, but the history and physical directed the ordering of the tests.

We received no quality points for making this diagnosis. Making important diagnoses is not part of performance measurement. The art of diagnosis may have saved this man’s life. It was important to the patient – and is not really the point?

Related posts:

1. Mystery novels and diagnosis
2. More on premature closure and mystery novels
3. Think before treating – diagnosis matters
4. Lisa Sanders on a patient with recurrent pain
5. What I said about pain control

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