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?
{ 3 comments… read them below or add one }
DB,
Correct me if I’m wrong, but what you’re saying is that anyone can practice reflexive medicine… the “You’d better get that checked out” and the physician’s job in that case is simply knowing knee pain gets test A, chest pain gets test C, abdominal pain gets test Q, etc.
But, the physician should really be a higher order multitopic structure. It’s something of interest to me that as I go through case presentations I always hear, with regard to missed diagnoses “Well, Dr. X should have ordered test Y, it’s elementary”, but I never hear “you know, if you would explore this more in the H&P you could also find L, M, N, O, & P before they get symptomatic”.
What I’m saying is that modern medical school is preparing us to be more procedure-focused physicians. For better or worse. Current models that I’ve seen don’t value contemplation on the individual patient. Instead, they’d rather get 80% of the diagnoses in the first 7.5 minutes, and then turf to a specialist, or a subspecialist, so they have their 7.5 minutes, too. Which, then leaves you with .8% of people who stump the subspecialists, right? What happens to them in our system?
-j
“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.”
I was speaking to a nurse this morning and the topic of her 76 year old brother-in-law came up. Obese, diabetic, failed hip and knee replacements which limits his mobility. Prior to leaving our cold winters for the South his doctor insisted on a stress test. He failed.
This was followed by an immediate heart cath. These are done in my community for the slimmest of reasons. The man suffered a mild stroke when a piece of plaque broke loose during the procedure. The local cardiologist declares “There is nothing we can do, try someone else.” Off to the major medical center where he is again told nothing can be done.
This guy’s long time physician certainly knew his condition. The original cardiologist knew the condition prior to the heart cath. Both doctors had to know these test were not going to change this person’s outcome, but yet were more than willing to do them.
So everyone go their 7.5 minutes. Everyone followed the guidelines. This guy’s insurance pays all the very large bills. This formerly outgoing person now sits at home asking: “Am I just suppose to sit here and die?”
Diagnosing and the proper use of testing are very important. Understanding that test carry their own risk factors is also an important issue. Understanding it is not about checking the box and getting paid but asking: Will this test make a difference in the outcome?
Steve Lucas
I’m the dermatologist blogger quoted above. Your points are well argued; I agree with you, as I said in the second part of my quote:
“… we must have both clinical skills and good judgment for using tests, but I am not sure that we have lost the art of diagnosis just because we now use more technologies to assist us.”
Perhaps I would add that highly sensitive diagnostic test still depend on the pre-test probability. If you order 20 random tests, one will likely be positive by chance alone, yet not have any clinical significance. It is the impeccable history and physical that leads you to order the correct test, however sophisticated or expensive they might be.