tag:blogger.com,1999:blog-25200961.post1493409158053771257..comments2024-03-14T09:50:40.819+00:00Comments on Dr Grumble: Diagnosis is the keyDr Grumblehttp://www.blogger.com/profile/04417731064007601504noreply@blogger.comBlogger18125tag:blogger.com,1999:blog-25200961.post-82387446926477793522009-11-04T07:19:06.071+00:002009-11-04T07:19:06.071+00:00Kenali dan Kunjungi Objek Wisata di Pandeglang
Key...<a rel="external" title="Kenali dan Kunjungi Objek Wisata di Pandeglang" href="http://zf-1221.blogspot.com/2009/08/kenali-dan-kunjungi-objek-wisata-di.html" rel="nofollow">Kenali dan Kunjungi Objek Wisata di Pandeglang</a><br /><a rel="external" title="Keyword Kenali Pandeglang" href="http://zf-1221.blogspot.com/2009/10/keyword-kenali-dan-kunjungi-objek.html" rel="nofollow">Keyword Kenali Pandeglang</a><br />Mohon dukungannya yach....?!<br />Semangat..semangat..!!<br /><a rel="external" title="Pandeglang telah hilang" href="http://zf-1221.blogspot.com/2009/09/telah-hilang-kenali-dan-kunjungi-objek.html" rel="nofollow">Pandeglang telah hilang</a> <a rel="external" title="Kenali Si Dunia Aneh" href="http://zf-1221.blogspot.com/2009/09/kenali-si-dunia-aneh.html" rel="nofollow">Kenali Si Dunia Aneh</a><br />Mari bersama <a rel="external" title="Pak Firman" href="http://pakfirman.blogspot.com" rel="nofollow">Pak Firman</a> yang bekerja di <a rel="external" title="SDIT Nurul Ilmi Medan" href="http://pakfirman.blogspot.com/2009/11/sdit-nurul-ilmi-medan.html" rel="nofollow">SDIT Nurul Ilmi Medan</a> dalam kontes <a rel="external" title="Kenali dan Kunjungi Objek Wisata di Pandeglang" href="http://kenalidankunjungiobjekwisatadipandeglang.inilahkita.com/2009/09/29/kenali-dan-kunjungi-objek-wisata-di-pandeglang/" rel="nofollow">Kenali dan Kunjungi Objek Wisata di Pandeglang</a>Kenali dan Kunjungi Objek Wisata di Pandeglanghttp://zf-1221.blogspot.com/2009/08/kenali-dan-kunjungi-objek-wisata-di.htmlnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-52549598858871947562009-05-21T09:36:00.238+01:002009-05-21T09:36:00.238+01:00diagnosis is 80% hisory,...very true jobbing docto...diagnosis is 80% hisory,...very true jobbing doctorWebmasterhttps://www.blogger.com/profile/05072978643296610700noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-29191043857842945722009-05-18T14:06:00.000+01:002009-05-18T14:06:00.000+01:00Sure. Great stuff on chest problems. But, actually...Sure. Great stuff on chest problems. But, actually, how does a chest physician start on the early presentation of, say, gynaecological problems?<br />*******************<br />You know my Achilles' heel, Dr C! Actually if you take, for example, the symptom of cough you will find whole papers written on this particulat topic - by chest physicians rather than GPs. My impression is that GPs see this symptom from a completely different angle - presumably because they see lots of acute coughs that go away with or without treatment. Chest physicians see the more mysterious coughs that have defeated the GP - but perhaps not all GPs.Dr Grumblehttps://www.blogger.com/profile/04417731064007601504noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-46234731955728088882009-05-18T13:42:00.000+01:002009-05-18T13:42:00.000+01:00I shan't be writing the book. Not on diagnosis any...I shan't be writing the book. Not on diagnosis anyway. It is just too difficult.<br /><br />We have an example in these comments of just how difficult it is to get across the distinction between reasonable diagnostic delay and unreasonable diagnostic delay. <br /><br />There is no point in speeding up diagnosis unless it alters the outcome. Many cancers have been present for years before they manifest themselves so, if you want to criticise, when it comes to bowel cancer the main problem is in not diagnosing the problem before there are any symptoms and that requires screening which is only now becoming available and is a system not individual doctor failure.Dr Grumblehttps://www.blogger.com/profile/04417731064007601504noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-40979788685712416932009-05-18T12:15:00.000+01:002009-05-18T12:15:00.000+01:00"Gawd, Sam, just about EVERYONE who goes to Egypt ..."Gawd, Sam, just about EVERYONE who goes to Egypt comes back with diarrhoea. It's the worst country in the world for it."<br /><br />I'll take your 'expert' word for it Dr C but .. does that mean the doc should therefore assume 'all he sees is sand' and allow a patient, who is otherwise well, to go for a 'whole month' without having an 'in your face' symptom like diarrhoea to go unchecked?! Pretty naive .. and incompetent if you ask me ...samnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-58305525681383678822009-05-18T11:59:00.000+01:002009-05-18T11:59:00.000+01:00"Refer all patients with diarrhoea for a week who ..."Refer all patients with diarrhoea for a week who have been to Egypt? What about the risks of sigmoidoscopy and Barium Enema?"<br /><br />I don't know JD about refering 'all' JD, what I know is that if the patient has been presenting with a diarrhoea for a 'full' week but is well and no other symptoms, then the doc should have suspected other reasons than Egypt being the cause. That the doc did not, shows 'his' limitations and the patient is right to question his judgement to delay tests.samnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-41754667115252980262009-05-18T11:44:00.000+01:002009-05-18T11:44:00.000+01:00Get the book written -you have an excellent writin...Get the book written -you have an excellent writing style. I'm sure that plenty of GPs will collaborate.<br /><br />++++<br /><br />Sure. Great stuff on chest problems. But, actually, how does a chest physician start on the early presentation of, say, gynaecological problmes?<br /><br /><br /><br />JohnDr John Crippennoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-21078351748552624832009-05-18T11:42:00.000+01:002009-05-18T11:42:00.000+01:00Shouldn't the fact that this patient was 'well' pr...Shouldn't the fact that this patient was 'well' prompted the GP to speed up the investigations Dr C? Especially because he's just been to Egypt, or a hot country hence Diarrhoea will always be accompanied with being unwell because such condition is 'always' microbial?<br /><br />++++<br /><br />Gawd, Sam, just about EVERYONE who goes to Egypt comes back with diarrhoea. It's the worst country in the world for it. And, beleive it or not, NOT everyone with travellers diarrhoea is particularly unwell. I daresay if he had been to an Egytian doctor he would have had a grand slam of treatment, probably with ciprofloxain, but that is not really appropriate.<br /><br />If you are saying that the Egyptian doc would have instantly diagnoed Ca Colon...well, I think that is unlikely.<br /><br />I susect that this chap DID have a non bacterial travellers diarrhoea and also happened to have another problem<br /><br /><br />JohnDr John Crippennoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-70963356331302892612009-05-18T10:25:00.000+01:002009-05-18T10:25:00.000+01:00Thank you for such an informative and thought prov...Thank you for such an informative and thought provoking blog.<br /><br />Get the book written -you have an excellent writing style. I'm sure that plenty of GPs will collaborate.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-3362919853637614242009-05-18T09:07:00.000+01:002009-05-18T09:07:00.000+01:00Managers forget that we have protocols all along, ...Managers forget that we have protocols all along, it is called medical training and the most important part of it is the apprenticeship whether we still like to call it that or not. The human mind works better (for now) than the best computer. We sometimes pick up clues when we see a patient that may not be obvious in a tick box scenario and we may by pass several steps in the “flow-chart” to reach a diagnosis or a list of differential diagnosis to then set up investigations. Even in psychiatry, two overdoses might have totally different management although they took the same number of tablets. If we are allowed to continue we save them money and we hopefully do not over investigate. <br /><br />That is why we need all that memory work so that the brain works on parallel processing and yet too many now rely on the computer to do that. The day will come when the ward round is carried out with an iPod, just like judges in the courts with their computer screens (yes, that is what they do now). One day lawyers too need not reel off quotes of cases by heart. <br /><br /><A HREF="http://cockroachcatcher.blogspot.com" REL="nofollow">The Cockroach Catcher</A>Cockroach Catcherhttps://www.blogger.com/profile/14440000294855006966noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-43565708030643418492009-05-18T07:58:00.000+01:002009-05-18T07:58:00.000+01:00It is entirely par for the course, but as misguide...It is entirely par for the course, but as misguided as ever, that a hospital consultant should be asked to write book about presenting symptomatology.<br />*************<br />Mrs Grumble had a book (we probably still have it somewhere) written by a GP which started with the symptom. She rarely opened it. I looked at it many years ago and thought it was remarkably useless. It failed to get across any of the nuances in diagnosis some of which you mention, Dr C. It is very difficult to do this in a book. That is the reason why so few of use have taken on the challenge to either write books on or research how it is we reach a diagnosis.<br /><br />Patients think a diagnosis is either right or wrong but really it is a hunch based on probabilities. It should be reviewed as time passes. Even Dr C talks about ‘missing diagnoses’ as if he has done some wrong but these are not errors. No computer could put you right. Quite often there simply is not enough information to get to a diagnosis and, contrary to what many may think, lots of tests are unlikely to help and could be counterproductive. <br /><br />My own feeling is that the way we get to a diagnosis is to do with very high level thinking that experienced humans can be good at but computers, at present anyway, are not. It would be nice to understand it a bit better but it is very difficult because it involves integrating all those very many things we know about a patient just some of which Dr C mentions.Dr Grumblehttps://www.blogger.com/profile/04417731064007601504noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-31786228672144522242009-05-18T06:58:00.000+01:002009-05-18T06:58:00.000+01:00What do you suggest, Sam?
Refer all patients with...What do you suggest, Sam?<br /><br />Refer all patients with diarrhoea for a week who have been to Egypt? What about the risks of sigmoidoscopy and Barium Enema?<br /><br />No, this is not a swipe at Lord D, as he doesn't see the mass of patients with Diarrhoea, it is just that Dr C's partner did everything right, but things don't always present logically or predictably.<br /><br />I find dealing with bowel symptoms in over 40s very hard to assess.<br /><br />Dr C. Get CT and MRI for your patch: it has transformed my management of back pain, knee problems and headaches.Jobbing Doctorhttps://www.blogger.com/profile/15556376882759955757noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-17345953045957446972009-05-17T23:59:00.000+01:002009-05-17T23:59:00.000+01:00'diarrhoea which has persisted for nearly a week, ...'diarrhoea which has persisted for nearly a week, not unwell'<br /><br />Shouldn't the fact that this patient was 'well' prompted the GP to speed up the investigations Dr C? Especially because he's just been to Egypt, or a hot country hence Diarrhoea will always be accompanied with being unwell because such condition is 'always' microbial? <br /><br />While I can understand your partner is not used to such cases because of the different climate, an Egyptian doc would've picked it straight away ... because they've seen 'it' many times before ... and no queues at the colorctal clinic would have been neccessary .. or sending postcards to Lord D either because I am sure he is aware of this dilemma :-)samnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-35707099173029036652009-05-17T22:53:00.000+01:002009-05-17T22:53:00.000+01:00Interesting article but possibly indicative of a w...Interesting article but possibly indicative of a worrying underlying trend. It is entirely par for the course, but as misguided as ever, that a hospital consultant should be asked to write book about presenting symptomatology. By the time the punter gets to hospital he has either been screened by a GP or self-screened by perceived urgency. Not to suggest that there are not diagnostic challenges on the front line of the hospital. Of course there are.<br /><br />But GPs frequently see diseases so early in their evolution that the standard medical texts are unhelpful. You rely on all sorts of clues. Personal knowledge of the patient : Mrs Bloggins has never presented with a persistent cough before so, although there are no signs, she DOES need a CXR. My favourite is the heavy smoker who you have known for years and whom you have unsuccessfully tried to persuade to stop smoking. One day he presents saying he wants "a check up" - no specific symptoms, no cough, no haemoptysis, no weight loss...but it emerges that he stopped smoking six weeks ago. It's lung cancer until proved otherwise. And so we can go on for ever and a day about the art of general practice rather than the science.<br /><br />Do GPs miss diagnoses on first presentation? Hell, yes, all the time. But we safety net, and bring them back and review, and usually get it the second time. Except that these days some of them have taken themselves to A & E where the diagnosis, now apparent, is made, and a junior doctor or nurse raises eyebrows when the patient asks why his own doctor did not make the diagnosis.<br /><br />In general practice, time is our friend and our enemy. Time - a few days - for something to develop and of course, occasionally, time still to miss something. <br /><br />Do I need a protocol, a list of 27 diagnoses for each symptom? No thanks. This is what the pharmacists have started to play with, and it's a nightmare.<br /><br />Would I like immediate same day access to CT and MRi? Sure. Who would not? Where I work, I don't have ANY access to CT and MRI. Would it improve my diagnostic success rate? Possibly. Not sure. <br /><br />Would it change the nature of my job. Yes it would. Totally. It would move me gradually from being a diagnostician, skilled at picking up disease early in its evolution, to being a protocol monkey. Maybe that is best. That is certainly where we are headed for, make no mistake. Once the primary care "clinicians" (I use that word in the way the Jobbing Doctor understands) take over that will be all he can offer. <br /><br />Just before Xmas a lady presented saying that she was feeling non-specifically unwell but the only thing she had noticed was that, when she was speaking, after about three sentences, her speech became slurred. And it did. I tested it. Could not otherwise convince myself of inappropriate muscle tiring, but on this history you have to exclude Myasthenia gravis. Did the test. It was positive. Referred her to the local neurologist (nice chap) and got letter back saying "must congratulate you on your diagnostic acumen". How charming, you may say. Passed it round the partners at coffee, and they all reached for the white telephone. He meant well, but it's bollocks. Not an appropriate thing for him to say. I would not ever write to him and congratulate him on his diagnostic acumen. I would not patronise him like that, and we do not expect him to patronise us. Early diagnosis is what we do. It's nice to get it first time. <br /><br />I would like to see more of the data on misdiagnosis in general practice. Are we talking of comparing final correct diagnosis with tentative diagnosis made on first presentation to the GP? I would like to see a trial on final diagnosis compared to the first two weeks of presentation in general practice. <br /><br />Example : change in bowel habit should be investigated in the middle aged. I read that on the back of a match box somewhere, so it must be true. But what is a "significant" change in bowel habit? <br /><br />A fifty eight year old comes back from Egypt with diarrhoea which has persisted for nearly a week. Not unwell. No blood. He sees the GP 3 times over next four weeks; first time, general advice, second time stool culture (negative), third time occult bloods X 3, two negative one positive. PR normal. No weight loss. Not anaemic. Tumour markers normal. No family history. Referred to colorectal clinic (NOT TWR as he does not meet the criteria). Seen six weeks later by Colorectal Nurse who does a sigmoidoscopy (normal) and decides to order a barium enema. This is done 4 weeks later. It shows a carcinoma in the upper part of the descending colon. <br /><br />Patient blamed GP for not making the diagnosis sooner and made a formal complaint, which he pursued vigourously with lawyers. Complaint was thrown out, but it was six months stress for my partner and for the whole practice. <br /><br />That's a real story that happened to one of my partner's and his patient. <br /><br />Bet that would show in the survey as delayed diagnosis? And it is a delayed diagnosis. BUT, is it culpable delay, or is it merely part of life's great tapestry. If you are to say there was fault, then that's fine by me. We will do a TWR referral on every case of diarrhoea presenting in anyone over the age of forty. How, then, will we deal with the queues outside the colo-rectal clinics?<br /><br />Answers on a postcard to Lord Darzi.<br /><br /><br /><br />John<br /><br />Phew! What a long comment. I was typing away half watching the increasingly lovely Dr Alice Roberts sledging in Siberia.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-79441714063285099812009-05-17T20:02:00.000+01:002009-05-17T20:02:00.000+01:00Mrs Dr Aust would agree with you, Dr G. She has a ...Mrs Dr Aust would agree with you, Dr G. She has a line something like:<br /><br />"If I had a bottle of champagne for every little old lady that came in with a fall who we finally diagnosed as having had an arrhythmia or a silent MI I'd have a cellar."<br /><br />- the point being that too often it was assumed (esp by jr. A&E and ortho folk) that all 70+ yr old ladies simply tripped over things and fell down. Mrs Dr A used to try to explain that the key was whether the lady had a reason to fall down, and that taking a proper history - largely to work out <I>how</I> fit and active and healthy (or not) - and thus likely to fall (or not)- the LOL was. <br /><br />Apart from in general medicine, she used to see the same "LOL fall fallacy" turning up pre-op in anaesthesia, where the LOL would be on the list for an emergency op to fix the broken bone w/out anyone having really asked why she fell in the first place.Dr Austhttp://draust.wordpress.comnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-73484584324626835042009-05-17T17:38:00.000+01:002009-05-17T17:38:00.000+01:00I agree with your proportions, JD. And your commen...I agree with your proportions, JD. And your comment about modern medicine.<br /><br />This is another thing that the managers don't seem to understand. They seem to want every scanner there is instantly available in the GP's polyclinic as if that is the key to diagnosis in primary care.Dr Grumblehttps://www.blogger.com/profile/02459592334604944530noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-87473012910028005052009-05-17T17:29:00.000+01:002009-05-17T17:29:00.000+01:00I'm sorry to make a 'Grumpy' triumvirate, but I do...I'm sorry to make a 'Grumpy' triumvirate, but I do agree with you both. The area where diagnosis is more tricky is primary care, where you don't already have the stuff pre-filtered as you do in hospital.<br /><br />I teach my students that diagnosis is 80% hisory, 10% examination and 10% investigation. modern medicine seems to demand the reverse.<br /><br />JD.Jobbing Doctorhttps://www.blogger.com/profile/15556376882759955757noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-51730536792116385952009-05-17T16:33:00.000+01:002009-05-17T16:33:00.000+01:00This is an iffy issue, and one that remains a seri...This is an iffy issue, and one that remains a serious one even in our age of high-tech gadgets and scans.<br /><br />I agree with you- management and pathways and protocols are sometimes semi-useful guidelines, but are NEVER a good substitute for a good clinician.<br /><br />The thinking process that goes into this is hard to characterize. Experience, exam findings, objective test data, etc, but there is also a degree of "gut feeling" and even luck.Grumpy, M.D.https://www.blogger.com/profile/09858110332436246760noreply@blogger.com