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).
This is both the beginning – and the cornerstone – of the diagnostic process.
The diagnosis is often in the very first words the patient says. S0, write them down.
Why? It is 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; these an 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.
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.
Regarding previous surgery, a good question is “have you had any major operations in the past?” This stops a long diatribe about whether they had their tonsils or adenoids (or both!) removed when they were 4 years old. Also, patients won’t always know what ‘surgery’ encompasses (and it can also be confused with their GP’s surgery).
Top Tip. Women are tougher than men and often do not mention Caesarians (a laporotomy, boys!), D&Cs and terminations. You may need to ask questions re surgery to women twice – e.g. “are you sure you have not had any operations?”
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.
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 (acute confusion) or dementia.
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 initially know which camp they fall into. A healthcare professional, on the other hand, should be able to describe a dispassionate, accurate record of any sign or symptom, in your quest for a diagnosis.
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 this 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.
This is not the mystical form of intuition, but the acquisition of subtle clues that you might not notice consciously but do register subliminally.
You get better at this as your career progresses. Doctors peak aged 40-60 years – yes, a long time to wait. Sorry.
If you are on the brink of studying medicine then you may already be skilled in reading people.
A furtive glance to a relative, a slight tremor or a transient frown could suggest that your consultation is unsatisfactory in some way – and you need to respond. Rephrase the question.
Many have amassed years of experience at the coal face. They 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.
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.
You will have deduced by now that we at MyHSN believe this 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 less. Even in this technological era, a good history still dictates where you are going to point your diagnostic tests.
Final Top 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. If you don’t, you need to practice (alot).
Listen to the media
Listen out for what topics are trending, not just 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. It 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.
