On The Case

White coats and fingerprints: diagnostic reasoning in medicine and investigative methods of fictional detectives

BMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.331.7531.1491 (Published 22 December 2005) Cite this as: BMJ 2005;331:1491
  1. Claudio Rapezzi, associate professor of cardiology (crapezzi@orsola-malpighi.med.unibo.it)1,
  2. Roberto Ferrari, professor of cardiology2,
  3. Angelo Branzi, professor of cardiology2
  1. 1Institute of Cardiology, University of Bologna, Italy
  2. 2 University of Ferrara and Cardiovascular Research Centre, Salvatore Maugeri Foundation IRCCS, Italy
  1. Correspondence to: C Rapezzi, Istituto di Cardiologia, Policlinico S Orsola-Malpighi, via Massarenti 9, 40138 Bologna, Italy
  • Accepted 27 September 2005

Current trends toward routine mass use of sophisticated diagnostic tools is killing off the science and art of clinical reasoning. An ideal clinician would present a harmonic fusion of almost all the investigative methods of fictional detectives and avoid slavish adherence to protocols and procedures

Our underlying premise is that the current trend towards mass use of sophisticated diagnostic tools in routine practice—accompanied by a blind faith in technology and predefined diagnostic algorithms—is threatening to kill off the science and art of clinical reasoning. Besides burning a lot of public and private money to make diagnostic work rather superficial, doctors also risk losing the intellectual pleasure that comes from careful diagnostic reasoning.

Clinical analogies with detective fiction generally revolve around Sherlock Holmes.1 2 However, like medicine, detective fiction has subspecialties and intellectual trends.3 A rapid overview of the analogies between diagnostic reasoning and the investigative strategies found in detective literature may provide us with some clues on how to confront the problems posed by the burgeoning number of available technologies.

Clinician-detective analogies

“Detective work” has long been a metaphor for clinical acumen. Clinical reasoning and the detective fiction genre show many similarities in their cultural background and context (box 1). Both try to restore a status quo that has been undermined by a crime or disease. During their golden age, the two disciplines thrived on a climate of faith in the apparently unlimited capabilities of science and based their methods on deterministic interpretation of clues, signs, and symptoms. Detectives and clinicians reach a final, reasoned “diagnosis” by decoding signs (clues) that are often meaningless or disconcerting to the layman. The stupor and admiration that Sherlock Holmes excites when he “guesses” through apparently insignificant details that Watson has been to send a telegram from the Wigmore Street post office4 is …

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