Letters

The changing doctor-patient relationship

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7238.873/a (Published 25 March 2000) Cite this as: BMJ 2000;320:873

Diagnoses are made from careful history and examination

  1. Vincent McAulay (vmcaulay{at}yahoo.com), research fellow.
  1. Royal Infirmary of Edinburgh, Edinburgh EH3 9YW
  2. PKC Corporation, Chace Mill, Box A-8, One Mill Street, Burlington, VT 05401, USA
  3. Groom Law Group, Chartered, 1701 Pennsylvania Avenue NW, Washington, DC 20006, USA

    EDITOR—I welcome the improved use of resources already available to us, but I must point out some facts to Weed and Weed.1 When we are medical students we are taught that more than 80% of diagnoses can be made on the basis of a careful history and physical examination. We are therefore taught to focus on individual symptoms and signs from which a differential diagnosis is formed and appropriate investigations are requested. I was certainly not taught to “focus on general knowledge about large populations.” Doctors in the United Kingdom undertake a period of general professional training and have to complete a difficult and highly competitive examination, before specialisation. The Weeds' case was from the United States, and many specialists were involved in the patient's care, which may have been a contributing factor to the delay in diagnosis.

    You cannot damn the whole of the medical profession on the basis of one case report. Addison's disease was top of my differential diagnosis by line four of the article, as would have been a Synacthen test to diagnose it.

    References

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    Authors' reply

    1. Lawrence L Weed (llw{at}pkc.com), president.,
    2. Lincoln Weed (ldw{at}groom.com), attorney
    1. Royal Infirmary of Edinburgh, Edinburgh EH3 9YW
    2. PKC Corporation, Chace Mill, Box A-8, One Mill Street, Burlington, VT 05401, USA
    3. Groom Law Group, Chartered, 1701 Pennsylvania Avenue NW, Washington, DC 20006, USA

      EDITOR—The medical profession remains in denial, judging from the responses of McAulay and Reinecke.1 By denying the limitations of the human mind, the profession only worsens the impossible burdens placed on it.

      McAulay indicates that British medical students are taught that most diagnoses can be made by focusing on individual symptoms and signs drawn from a “careful” history and physical examination. We do not question that British (and American) medical students are taught this. Our point is that in practice what they are taught cannot be consistently achieved—unless medical practice changes fundamentally. The reality for most patients is that their doctors are not given the opportunity to conduct a truly careful history and physical examination or to analyse thoroughly the resulting mass of data. And even when doctors have that opportunity, they still may err. Their personal store of knowledge may be insufficient, they may be unable to apply their knowledge correctly to an actual patient, or that “knowledge” may itself be fallible and incomplete. Isolated fragments of general knowledge about large populations can easily mislead, for example, because doctors are unable to combine detailed patient data with the myriad fragments of knowledge relevant to complex, unique problems.

      Perhaps some readers believe that such conclusions do not apply to highly trained doctors who, like McAulay, sometimes can quickly recognise the correct diagnosis when reading a case report. Yet many talented doctors “find that the skills that allowed them to excel in the classroom, and even as house officers, are of little use … when they are faced with a flood of information” in a typical medical practice.2 Moreover, even if some doctors believe that they experience no such difficulties, what is to be done for the patients of other doctors, or for people without access to doctors?

      Contrary to Reinecke's view, 1 we do not “totally discount” the experienced doctor's intuition. On the contrary, Reinecke's description of what contributes to that intuition—years of training; intimate and confidential contact with the patient; the combination of visual, aural, and sensory functions of the brain; telephone conversations and chance remarks in passing—buttresses our thesis. Reinecke's own description shows that sound medical decision making depends on coupling detailed data with comprehensive medical knowledge. And his description shows that present approaches to that coupling process, such as “chance remarks in passing,” are insufficient.

      Software tools do not replace the doctor's intuition; they empower it. If doctors find help in telephone conversations and chance remarks from colleagues, then they can find enormous help in software that illuminates the connections between data from individual patients and medical knowledge in every encounter with patients. Practitioners who have used knowledge coupling software have written of how much more gratifying medical practice becomes with such a tool.3 4

      References

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