10 Top Tips for Making a Successful Medical Diagnosis
Here are 10 Top Tips top help you make a successful medical diagnosis.
Making a clear diagnosis is the primary function of all types of doctor. And, 80% of diagnoses, are based on the history alone (Hampton et al, 1975).
1. Listen to the very first words the patient says very carefully (presenting complaint, PC). Then listen to history of presenting complaint (HPC)
This is both the beginning and the cornerstone of the diagnostic process.
The diagnosis is often in the very first words the patient says. Write it down.
It’s the key reason(s) why the patient is seeking medical help. So resist the temptation to jump in with your set of pre-rehearsed questions, and listen. Sometimes this is straight-forward, but unfortunately we humans are complex creatures.
We carry our own set of unique expectations, driven by culture, taboos and individual eccentricities that can lead to cross-wires and an unfulfilled consultation.
Explore their ideas, concerns and expectations (ICE). This is a model used especially in General Practice that adds a visceral dimension to the complaint. “What do you think is causing the problem?” (Ideas); “Do you have any particular worries about this?” (Concerns), and “what were you hoping from this visit?”. Ask them these questions at the end of the medical history.
One big tip is that cancer is a huge worry and is often lurking in the back of patients’ minds.
2. Listen to the past medical history (PMH)
The past can sometimes point to the present. The patient may present with a flare up of a previous medical condition, or may suffer a complication of a previous problem.
For example a patient who has had previous bowel surgery can develop an acute bowel obstruction because of adhesions produced by the past surgery.
Conversely it can help by ruling out a possibility. A patient with right lower quadrant pain in the abdomen cannot have appendicitis if the appendix has already been removed.
3. Listen to the drug history (DH)
Up to 10% hospital admissions are due to adverse drug reactions (ADRs). As these are under-reported it’s likely to be even more.
And this does not include expected side effects from medication or even the misery patients can experience due to errors in drug prescription. They can be a powerful source of suffering and to paraphrase an old saying ..
Drugs are poisons with the occasional beneficial side effects”
So beware and be aware.
4. Listen to carers
The carers will have invaluable insights into the patient’s problems and their behaviour. They are indispensable when it comes to certain presentations such as blackouts, where an eye-witness account is essential, or if the patient has a poor memory for reasons such as delirium or dementia.
5. Listen to other health care professionals
This can be nurses, health care assistants, therapists, or anyone who has been in contact with your patient. People vary in how they report signs and symptoms. Some exaggerate, some underplay their symptoms and some get it just right (Goldilocks patients).
Unfortunately you don’t always know which camp they fall into. A healthcare professional, on the other hand, should be able to give you a dispassionate, accurate record of any sign or symptom to help in your quest for a diagnosis.
6. Listen to what is not said
This tip may only be needed occasionally but can be powerful if spotted. For example, a man had repeated admissions to hospital with chest pain. And yet when he arrived, he often seemed to be well and was certainly independent. He did however have a wife who had advanced dementia.
The penny dropped later in his admission. Most patients who have a sick relative are anxious to go home so they can look after their spouse, sometimes putting their own health in jeopardy.
However, at no point did this man mention his wife to anyone. It wasn’t because he didn’t love his wife, but, rather than admit he couldn’t cope, he escaped his dilemma by assuming the sick role and getting himself admitted.
7. Listen to your intuition
This is not the mystical form of intuition, but the acquisition of subtle clues that you might not notice consciously but do register subliminally.
If you are on the brink of studying medicine then you may already be skilled in reading people.
A furtive glance, a slight tremor or a transient frown could suggest that your consultation is unsatisfactory in some way and you need to respond. Consider rephrasing the question.
8. Listen to your teachers
Many have amassed years of experience at the coal face and have tips and tricks that can enhance your ability to diagnose as well as other aspects of managing patients.
They can certainly help you unravel those knotty problems that are not explained well in textbooks.
Ask them. They became doctors for the same reason as you .. to make people better.
9. Observe
Watch your patient carefully – using all your senses.
Observation is 90% of medicine”
Start looking at them as they get out of the chair in the waiting room. What is their biological age? Are they short of breath? In pain (where?)? What does their gait tell you? Walking ability? What is their demographic background? What are they reading? Why?
There is often important information in the body language of a patient. Watch them carefully. A subtle change in eye contact or the timbre of the voice, just at the right instant, is sometimes the only clue to an otherwise missed diagnosis (physical or mental).
A patient that frequently turns to their partner for the answer to a question can often be a clue to underlying cognitive impairment.
10. Listen (again!)
You will have deduced by now what we at MyHSN believe is the most important clinical skill. Doctors are very good at talking but less good at listening. You need to address this issue.
As stated above, diagnosis is 80% history and 20% examination/investigation (to confirm your suspicions).
When you become a good historian, you will need examination and investigation even less. Even in this technological era, a good history still dictates where you are going to point your diagnostics.
What is my final tip? If you have got to the stage where you are reading tips for clinical skills we would guess you will have acquired an expensive bit of kit called a stethoscope. If so, you should know exactly what to do with it.
Bonus Top Tip
Listen to the media
Listen out for what topics are trending, not only for your own education but because your patients will be doing so as well.
This may bring the worried well flocking to your door for reassurance but may also include patients whose hopes have been raised by the latest breakthrough, or those who are alarmed because of potential epidemics like COVID-19, Swine-flu, and Ebola
