Medical Diagnosis: Test First, Talk Later?
More than half of all outpatient physician visits are triggered by common symptoms, such as dizziness, back pain, fatigue, headache, cough, and other respiratory complaints. Dr. Kurt Kroenke, a professor of medicine at Indiana University, after years of studying common complains, reported at a recent American College of Physicians meeting that in addition, three-quarters of patients who present with these common complaints experienced improvement in two weeks. At least one-third of all symptoms are medically unexplained, so testing will not reveal a precise diagnosis and is therefore useless.
Twenty years ago researchers found that on average, patients were interrupted 18 seconds after beginning to explain their complaints and problems. The findings in the original study by Dr. Sherrie H. Kaplan at the University of California, Irvine, were essentially confirmed 15 years later in follow-up by members of the same group in 1999 and reported in the JAMA. Just how often does communication between doctors and patients collapse? Research shows that only 15% of patients fully understand what their doctors tell them, and 50% leave their doctorsí offices unclear about the advice they received. Fewer than 2% of patients got to finish their explanations. Dr. Kaplanís studies suggest that the typical number of questions women ask during a 15 minute visit is six, while a male patient asks none.
Many physicians, possibly the majority, continue to neglect the long-honored tradition of first listening to the patientís description of his complaint, then performing an appropriate physical examination. All too often, this time-tested but sadly neglected approach has been subordinated to the pressures of time and the indiscriminate ordering of various testing procedures in a misguided search for some shortcut to a diagnosis.
The format and style of our Easydiagnosis website is intended to reflect long-accepted medical wisdom, that signs and symptoms, and therefore a careful medical history and physical examination provide the major clue to the correct diagnosis in over 80%-90% of cases. Fifty years ago, Platt asserted that most diagnoses could be made on history alone. More than a century ago, Dr. William Osler, the great clinical teacher, exhorted his students, "Listen to the patient, He is telling you the diagnosis."
In an age of exploding technology the problem remains the survival of common sense medicine, and the preservation of clinical judgment. Physicians - and patients - are overwhelmed by the vast proliferation of newer techniques in the laboratory and in diagnostic imaging, many of which were unheard of only a few years ago. We have seen such hi-tech procedures increasingly misunderstood and overused because of the sheer confusion caused by increasing numbers of competing and overlapping procedures. There appears to be a widespread assumption that the latest enhancement will automatically become the procedure of choice. For example, routine endoscopic studies of the gastrointestinal tract, expensive, uncomfortable enough to require anesthesia, sometimes dangerous, even fatal, have all but replaced reliable and safe barium contrast studies in the mistaken belief that the new is necessarily better than the old, and time-tested approaches are somehow quaint and should be regarded with deep skepticism. MRI/CT of the spine is non-revealing in over 85% of patients with low back pain, while in headache, MRI and CT scanning are a waste of time and money except in that one patient in a thousand with a specific neurologic indication which would have been revealed by history or examination.
Marginalizing the clinical approach is a result of our love affair with any form of novelty. To paraphrase Andy Worhol, in the future, every new test and therapy "will be famous for 15 minutes." Aldous Huxley, the author of Brave New World, once defined progress as "better toys."
It is no surprise, therefore, that the clinical approach to many sick patients has evolved into investigative anarchy, a kind of "scattershot" process in which every conceivable relevant or irrelevant diagnostic study is ordered as soon as possible. "Plugging the patient into the laboratory" accurately describes this kind of mindless medicine, driven by a perceived need to make a diagnosis or "do something" as fast as possible. Fear of malpractice litigation is also used to justify needless procedures because of the entrenched belief that the more tests ordered, the less the likelihood of being sued. All too often this proves to be a fallacy which can backfire, especially when extraneous tests disclose some irrelevant finding that now mandates still further procedures that are not pertinent and in turn may lead to various types of clinical disasters, the so-called "cascade effect."
This need not be a routine consequence of scientific progress. Every new technology brings with it the peril of being misapplied or abused when it is not viewed in proper perspective. This is certainly not the fault of technology. The vast majority of patients present with one of 30-40 major complaints. Most of the conditions causing these symptoms do not require any diagnostic testing, as Dr. Kroenke and others have demonstrated.
Even if health insurance carriers are foolish enough to consistently pay for whatever the doctor orders, patients are not forbidden to ask "why all these tests?" and physicians are not thereby excused from listening to the patient tell him, sometimes in excruciating detail, where it hurts.
Practical and sensible advice: Do not agree to any but routine medical testing, such as blood tests and plain or barium contrast X-rays without first insisting on a complete and coherent explanation. If you are advised to have expensive (CT or MRI) or invasive (and possibly risky) diagnostic procedures, such as, endoscopy, or cardiac catheterization, make sure you understand why such tests are indicated, and whether the results of such testing will affect the course of treatment.
Martin F. Sturman, MD, FACP
Copyright 2004, Mathemedics, Inc.
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