Friday, November 7, 2008

Diagnostic Acumen

I have spent a lot of time pondering what makes a good physician and have come to some conclusions. While medicare and other rating companies are developing lists of what constitutes good medical care.....I think they miss the point. Sure it's nice if hgb a1c's are checked every three months. Sure its important to make sure every patient with coronary disease is on a beta blocker. I won't argue with that. But in my mind what makes a good physician is not soo cookbook.

In my mind what makes a good physician is diagnostic acumen. In otherwords, how quickley will your physician diagnose and treat your problem correctly. Without a keen mind for diagnosis, a physician is average at best. They will continously miss important clues and often fail to prevent their patients from life altering consequences.

A few months ago I read Jerome Groopman's book, How Doctors Think, and continue to study medical decision making. How I think about a given problem often dictates my success or failure to diagnose. It's something I will spend my whole career doing. I especially remember the times when I miss diagnosis. This really burns me.

The other day I saw and elderly anxious lady with back pain. I examined her thoroughly. Asked many questions. And the pain seem to be muscular. But it was getting worse. So I set her up with an xray to rule out a spinal fracture. The xray was negative. When I called today she told me the pain was gettign worse.

So I did what I normally do in this situation. I asked her to come back to be reexamined. She was not happy. As I felt her temper rising I explained that sometimes when the answer is not apparent we have to start again at the beginning. Take a fresh look at the information and make sure nothing is missed.

She eventually agreed....and came for a visit. After a few minutes of questioning I lifted her shirt to find on her back a typical shingles rash. It had not been there two days ago. I treated her with valtrex and narcotics. Nothing earth shattering here but a simple answer to a simple question.

It's something I have to teach myself over and over again. If things don't make sense take another look. Start again. Don't be too intellectualy lazy or afraid to help those in need.

1 comment:

Toni Brayer, MD said...

Well said. Dr. Gwande (author of "Better") also mentions diligence as a trait of an excellent physician. Diagnostic acumen, diligence and kindness might be the magic trio.