Intended for healthcare professionals

Observations Ethics Man

How good a doctor do you need to be?

BMJ 2012; 345 doi: (Published 21 November 2012) Cite this as: BMJ 2012;345:e7858

Re: How good a doctor do you need to be?

I am responding to the rapid response posted by Jason Maude, CEO and Founder of Isabel Healthcare (which produces a diagnosis checklist system), who raised the issue if the doctor should be considered negligent if he/she failed to use a readily available and validated tool to help diagnosis.

For your attention, I need to point out a few key points listed in the main article "How good a doctor do you need to be?"

1. Bolam case uses the practice of medicine with reference to responsible body of medical practitioner as benchmark

2. Bolitho case says the judge will be entitled to choose between two bodies of expert opinion and to reject an opinion which is 'logically indefensible' in the judge's opinion.

3. Bailey case clarify the idea that where "but for" uncertainty in whether the defendent materially increased the risk of harm, the relaxation of the burden to prove sufficient causal connection to be liable in negligence

I am not aware of any tool that conclusively gives the diagnosis of a condition suffered by an individual. Medical science and evidence changes often enough and in spite of evidence-based medicine, still requires a consensus from expert specialists to regularly update the latest guidelines and diagnostic criteria.

I had reviewed your website and tested the sample page but not your actual product. I do not find it more helpful at all. Your tool listed no lest than 34 differential diagnoses for a young adult male (17 - 29 yrs) who travelled North America with symptoms of abdominal pain, arthritis, hematuria, elevated ESR and leukoscytosis, including Diverticulosis, osteomyelitis/septic arthritis and Endocarditis.

Frankly speaking if I just wanted a long differential diagnosis list I just use any internet search engine. With a very long list, I am sure one of the possible diagnosis will fit 99% of all patients with that symptom combination.

As a result, I will not find myself in negligence for not using your tool. However I am worried about how you "validate" your tool. Testimonials from doctors are not vigorous validation.

A doctor who is well taught and learnt the lessons from medical school, done the clerkship and know how to use general internet tools or books to cover the gap he/she is aware of, will not find your tool helpful, in fact it distracts the user from the main business of medical care now, by ordering unnecessary investigations.

Excluding the field of oncology, the age of diagnosis and (most of the) treatment has arrived for a long time. Most of the patients do not have problems in diagnosis or deciding which treatment they need; it is actually getting the treatment itself in the era of managed care or limited health care resources.

Competing interests: I am a medical doctor

26 November 2012
Shyan Goh
Orthopaedic Registrar
NSW Health
Sydney Australia