Medicine at a Glance 4th Edition PDF
64.28 MB PDF
Despite appearances, modern medicine in many ways remains old-fashioned. Empathy, compassion, efficiency, tact, knowledge, motor skills, resilience, kindness, all matter as much as always, but nothing matters as much as the ability to make a diagnosis. Diagnosis is central to everything doctors do; unless we establish what the problem is correctly, we cannot give the right treatment. Furthermore, our diagnostic skills cannot rest once we have made the initial diagnosis, we need to keep re-evaluating the diagnosis in response to treatment, and be aware that as treatment progresses new diagnoses may emerge, indeed, often do. Indeed, one could say that the unique role a doctor carries out in the modern health care system is to make a diagnosis and take responsibility for it. Almost everything else doctors do can be done by others, for example, by nurses, technicians, social workers, etc. What we do that uniquely adds value, and considerable value (so justifying doctors high salaries), is being an effective diagnostician. So, the skill that you should learn during your undergraduate and training years above all others is how to make a diagnosis.
How do doctors make a diagnosis? It is not easy to explain the thought process that leads to a diagnosis and it will vary between cases from a snap decision to a very carefully considered process. To make a diagnosis you need knowledge, and skills – skills in history taking, examination, and interpretation of diagnostic tests, understanding their strengths and weaknesses. Clearly, a diagnosis should fit the key facts of the case – the demographics, the symptoms and, if present, the signs (and perhaps just as importantly, the absence of signs indicating other diagnoses). The problem is that usually there is not just one possible, or even probable diagnosis, there are a number, there is a differential diagnosis. You should establish this differential diagnosis for every case. The thoughts that you put into this process is what will make you a doctor. My advice would be to list the two most likely diagnoses, and then the most likely dangerous diagnosis. This approach will work in many cases, but not all; for these you will need to have more possible diagnoses up your sleeve! Over time, you will look forward to the less than straightforward challenges. They can be frustrating, provoke great anxiety on your part, but eventually they are what make you a doctor.
I would like to add a very short word on what diagnosis is not – too many times I see written in the notes as the diagnosis ‘Chest pain? cause’, or ‘Exclude ACS’, or ‘ACS’ (as if there is no other diagnoses). All of these are wrong, and indicate the sort of thinking that will damage your patient (you will miss profound and serious diagnoses unless you actually think of them), and possibly lead you to the law courts (‘chest pain? cause’ for example means that you are unlikely to have thought of aortic dissection, you will therefore miss the diagnosis, and your patient may die). I cannot emphasise strongly enough that you must not use these sorts of vague or syndromic diagnoses, you must carefully construct a differential diagnosis for all your patients, for their sake and yours.
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