Making a successful clinical diagnosis is one of the most important things a medical student can learn, and it’s not as easy as matching a list of symptoms to a condition or illness. Editor of Clinical Skills, T. A. Roper, gives us a run-down of ten tips and skills he deems most important for making a successful clinical diagnosis.
Listen to the presenting complaint.
This is both the beginning and the cornerstone of the diagnostic process. 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); a model used 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?” One big tip is that cancer is a huge worry and is often lurking in the back of patients’ minds.
Listen to the past medical history.
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.
Listen to the drug history.
According to the National Institute for Health and Care Institute (NICE), it is estimated that 6-7% of hospital admissions are due to adverse drug reactions. As these are under-reported it’s likely to be even more. 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.
Listen to the carers.
The carers will have invaluable insights into the patient’s problems and their behaviour. They’re 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.
Listen to the 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.
Listen to what is not said.
This tip may only be needed occasionally but can be powerful if spotted. I looked after a man who 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 during his time with us 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.
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.
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.
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 Sars, Swine-flu, and Ebola.
You will have deduced by now what I believe is the most important clinical skill. It is often said that diagnosis is 80% history and 20% examination (to confirm your suspicions). 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 I am guessing you will have acquired an expensive bit of kit called a stethoscope. If so, I have a strong hunch that you know exactly what to do with it.