Diagnosis is the key

There are not many articles in the Health Services Journal that set Dr Grumble alight. Management is pretty boring. But management is important which is why Dr Grumble keeps an eye on the HSJ just as they keep an eye on him. Managers often seem to get hold of the wrong end of the stick. Putting them right is a challenge. They come from a culture of suspicion - especially about doctors - so sometimes they just won't listen. Doctors who go into management are not always a solution to this problem. Doctors who choose to head for management are not necessarily the best individuals we have on offer and they tend to go native. Patients and quality of care quickly get forgotten. Spreadsheets and targets rule their day. And thinking goes out of the window. Too many managers, medical or otherwise, are like puppets on strings.

Perhaps that is why managers, medical and otherwise, want to turn clinical care into puppetry. Issue doctors with protocols and patient pathways, give them a few boxes to tick and problems will just disappear. That anyway is how managers think it should be done. But it is not as easy as that. Protocols may require, say, the correct interpretation of an X-ray and junior doctors required to follow the protocol may not be able to read the relevant radiograph accurately. Managers fail to grasp this. To them a broken bone is a broken bone. If a doctor can't see a fracture managers see that as odd. They will rectify the problem by sending the relevant staff on a half-day course to put right what is really a lack of experiential learning. But you cannot make up for lack of experience by going on a course. You can't tell a manager that. A broken bone is a broken bone. You can see it on an X-ray. They know that. The concept that it might actually be quite difficult and need a lot of practice escapes managers. They will tell you that practising medicine is like flying a plane. All you need is the right simulator.

Dr Grumble has often seen the wrong pathway followed because the diagnosis was wrong in the first place. This happens because diagnosis is not easy. If you have, say, a pain in the knee and the X-ray shows something wrong in the knee it may seem as if you are home and dry but it could be that the pain is actually a result of pathology in the hip. Even orthopaedics may not be straightforward. You don't want your knee replaced if the problem is in your hip.

On more that one occasion Dr Grumble has been asked by publishers to write a book - not on particular diseases but on symptoms. Instead of there being chapters on heart attacks or pulmonary embolism, there would be chapters on chest pain and breathlessness. Even publishers seem to understand that patients do not arrive at the GPs' surgery with pulmonary emboli - they come with breathlessness or some other symptom. Yet, if you look at standard textbooks, you will find plenty of good articles on pulmonary embolism or myocardial infarction and rather few on how to diagnose chest pain or breathlessness.

Goaded by his would-be publishers, Dr G has learned that surprisingly little is known about how doctors make diagnoses. Many of Dr Grumble's colleagues think that today's junior doctors are not as good as they were. Even the juniors themselves, worn down by MTAS and MMC, are beginning to believe this. It is nonsense. It is very difficult to recall what you once did not know. Experiential learning sinks in slowly. You carry it with you for ever and it is the key to diagnosis. Unlike some of his more arrogant colleagues, Dr Grumble can remember when as a junior doctor he would struggle to get to the nub of a patient's problem when the consultant seemed to be able to score a hole in one without even trying. Dr Grumble did this himself the other day with a case of mitral stenosis. A few seconds auscultation and, despite the near-by vacuum cleaner, Dr G was able to describe the tell-tale murmur and even made a few comments about the pre-systolic accentuation. You can't do this unless you have had experience. Few of Dr Grumble's junior doctors have heard such a murmur before. Often diagnosis is more subtle than a single physical sign but Dr Grumble can still, sometimes, find it easy to get there despite red herrings fed his way. Surprisingly, it seems that rather little is known about how experienced doctors are able to do this. The books say it is something to do with heuristics which seems to Dr Grumble to be a way of saying we don't know quite how it is done.

Given the importance of diagnosis, it is odd that there has not been more research on how it is we reach or fail to reach this crucial bottom line. Dr Grumble thinks it is for the same reason that Dr Grumble has, mostly, avoided writing book chapters focussing on symptoms rather than disease. He has done it and some lectures too but it is not easy if your audience is senior. Like most, Dr Grumble has tended put the topic of diagnosis into the too-difficult basket. The relative lack of research in this area probably has the same cause. It's just too difficult.

On the other hand Dr Grumble spends a long time with medical students trying to teach them how to reach a diagnosis or, better, a differential diagnosis. Diagnosis is what most of Dr Grumble's bedside teaching is about. An old lady falls over. The notes read 'impression: mechanical fall' because she tripped over a rug. There is no thinking here. No differential diagnosis. Dr Grumble has rugs at home. He has never fallen as a result. So when an old lady falls what could it be that has caused it? How do we find out? What things should we consider? Students don't always appreciate such teaching because you have to make them work. You have to get them to think on their feet. Any thinking will do. There are no right or wrong answers - though the students tend to think there are. The old lady could have fallen because she lost her glasses or because of postural hypotension or very many other things. The problem is considering all these possibilities and working out which it is.

So what is all this to do with the HSJ? It is that the HSJ has actually got a rather good article addressing the issue of diagnosis. The managers have at last realised how crucial this is. They have discovered that:

...... of 840 emergency admissions, revealed five (0.6 per cent) had been diagnosed incorrectly - all by junior doctors.

Dr Grumble would like to know more about this study because he doesn't think he performs anything like as well that. And it seems particularly surprising given that even in intensive care we are told:

.....one study found major diagnostic discrepancies at post-mortem in one in five patients who died on an intensive care unit.

Probably what this discrepancy shows is just how little we know about this topic. Dr Grumble has some awareness of his own deficiencies but he comes from an era when we did many more post mortems. Our bosses insisted on it because they knew that their diagnoses were often wrong and that they needed to know when they were wrong. These days we never find out just how wrong we were.

Anyway, the HSJ article is a good one and well worth a read.