At the Core of What Physicians Do

“Introduction to Clinical Diagnosis” is usually medical students’ first introduction to what will become the very essence of what they will do during the rest of their professional lives.  From the first time that we as medical students doffed our short white coats and sat across from and started asking our first unsuspecting patients a highly scripted series of questions, we had begun a long process of professional discovery, not just of our patients, but of ourselves.

As physicians to be, we were all taught to listen to patients (and their family members).   We were admonished to discover as much as possible from the history of present illness (as well as the past and family history) before even beginning any kind of physical exam, much less to form any initial impressions about the pathology which could explain current symptoms and complaints.   Whether we had ever learned to do it effectively before that time in any type of person to person interaction, we needed to be taught to communicate in a way which was both professional, yet sufficiently personal to get patients to reveal information they otherwise might not, which could be critical to arriving at an accurate diagnosis.

Many medical student classmates of mine became inpatient during this “Introduction to Clinical Diagnosis” course.  They wanted to move on as quickly as possible to the process of ordering tests and procedures to make diagnoses and prescribe treatments.  However, the best clinician teachers fought their own tendencies to enable this kind of behavior in their students.  The more the ability to undertake thoughtful (and often time consuming) consideration of patient information obtained through detailed, logical questioning of patients is ingrained at the earliest stages in professional training, the more likely this skill will not be abandoned in later professional practice.

What Happens Later in How Doctors Think

As most physicians (and patients) know, in actual practice, physicians, on average, interrupt patients less than 18 seconds after they have begun relating their history of present illness.   In the so-called “real world” of medical practice, something called “pattern recognition” supplants the need to systematically communicate with patients to elicit key information critical to effective diagnostic decision making.  As Dr. Jerome Groopman, Professor of Medicine at Harvard, calls it in his landmark best selling book “How Doctors Think”; Houghton Mifflin (2007) :  “The doctor instantly and semiconsciously assimilates the relevant data, compares it with past cases and comes to a decision.  The mind acts like a magnet, pulling in the cues from all directions.”

This thought process leads to faulty decision making leading to the 15 to 20% of patients who are ultimately misdiagnosed with harmful, often deadly, consequences:  According to Dr. Groopman, along the way subtle influences skew decisions.  In emergency rooms which take in a large number of alcoholics, a patient “fitting that pattern” (who is actually in insulin shock) is often lumped in as just another “one of them”.