Getting it right: the challenge and reward of clinical diagnosis

acp new logoA guest column by the American College of Physicians, exclusive to KevinMD.com.

It was actually a great diagnosis that led me to become an internist.

I distinctly recall a patient admitted to my service during my third-year internal medicine clerkship inpatient rotation. He was extremely sick and what was wrong with him had eluded multiple other physicians before he ultimately landed in my hospital.

Through disciplined, methodical, logical thinking and focused testing, his diagnosis eventually became clear — eosinophilic granulomatosis with polyangiitis (what in those days was known as Churg-Strauss syndrome). I watched with amazement his rapid improvement before our very eyes following the start of glucocorticoid therapy. We had saved his life by making the correct diagnosis.

I remember thinking to myself about the physicians on my team while watching this process unfold: I want to know as much medicine as they do; I want to be as wise as they are; I want to be able to think like they do.

The ability to use “brain power” to diagnose and ultimately treat patients was what attracted me to internal medicine, and the opportunity to do this has been an incredible source of professional satisfaction throughout my career. And I am not alone – on a recent survey of ACP members, almost 90 percent expressed satisfaction with their career in medicine, and over two-thirds of this group indicated that it is the intellectual stimulation associated with their practice that is the most rewarding aspect of their job. I suspect the ability to diagnose disease in medically complex patients is a key aspect of that intellectual stimulation. And although patients and diseases differ greatly across medical specialties, making correct diagnoses and acting upon them is one of the great joys we all share as physicians.

Yet, there is substantial evidence that we are not as good as we should be at this core function of being a doctor. The National Academy of Medicine’s report Improving Diagnosis in Health Care published in 2015 estimated that diagnostic error contributes to as many as 10 percent of patient deaths, not to mention causing an even higher percentage of adverse events. This degree of diagnostic error not only profoundly affects our patients but can also have a devastating impact on us personally.

While some diagnostic errors are clearly attributable to healthcare systems that are not structured to promote diagnostic accuracy and safety, there is no getting around the fact that as physicians we may not be adequately focusing on the process of making correct diagnoses, or in other words, paying attention to the thinking part of medicine.

So how do we confront the paradox that one of the most important things we do as physicians and one that provides such great professional reward is also one where we consistently fall short to the detriment of our patients and ourselves?

It is helpful to realize that this is not a new issue or one that is unique to our current healthcare environment; William Osler had much to say about this over a century ago, and there is much to learn from his observations. He recognized that learning to be an effective diagnostician is perhaps the hardest part of becoming a physician, and that the ongoing challenge of making accurate diagnoses is an unavoidable aspect of caring for patients. He presciently described medicine as “a science of uncertainty and an art of probability,” and acknowledged the stressful nature of the process, particularly when we are faced with diagnostic uncertainty:

“In seeking absolute truth, we aim at the unattainable, and must be content with finding broken portions.”

And he believed that effective physicians learn to manage this uncertainty specifically by focusing on the thinking part of medicine.

A wise teacher early in my career put this into a helpful perspective. He told me that you can either embrace the challenge of diagnostic uncertainty or let it overwhelm you.

If it overwhelms you, you may become overly reliant on technology and the opinions of others in an attempt to reassure yourself beyond any doubt of the accuracy of your diagnosis, something that Osler noted is difficult to achieve, and we know may be harmful to patients and wasteful of valuable resources. It also makes the diagnostic process perpetually uncomfortable and takes away much of the personal joy in the day-to-day activities of being a physician.

If you embrace diagnostic uncertainty, you prepare yourself by learning as much medicine in your field as you can (as many of us heard as trainees, “you can’t diagnose what you don’t know”), honing your clinical skills (such as the history and physical examination as these are the true foundations for making accurate diagnoses), understanding the clinical reasoning process and its potential pitfalls, drawing upon your accumulated clinical experience, and engaging in diagnostic contemplation, particularly when confronted with complex clinical situations. You then apply what you know to your patients in a thoughtful, logical, and intentional manner with an understanding that absolute diagnostic certainty is often impossible to achieve, but that in applying your “brain power” to the diagnostic process you are using all of the resources available to help your patients.

Will doing this prevent us from ever making diagnostic mistakes? Certainly not, but the true reward in the imperfect art of clinical diagnosis comes not from being correct 100 percent of the time, but rather knowing that you’ve done everything possible you can to “get it right.”

Philip A. Masters is vice-president, Membership and International Programs, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

Image credit: Shutterstock.com

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