FOR THE SAKE OF ARGUMENT
WE'RE FORGETTING HOW TO DIAGNOSE SICKNESS
Dr. Alton Goldbloom
Today's physicians, says one of them, rely too much on their miraculous mechanical aids, and not enough on their own judgment. The result is that the art of diagnosis is dying and the real loser is the patient
TREATING THE SICK is a science, hut discovering what sickness to treat is an art. This art is called diagnosis, and lately I see more and more signs that despite the miracles of modern medical science, or maybe because of them, diagnosis is in some danger of becoming a lost art. And if diagnosis is in danger, many patients are in danger too.
What is happening it seems to me, is this: the modern medical laboratory is providing physicians with any number of chemical and biological tests that measure what’s going on in a patient’s body. A truly baffled doctor can now order as many as two hundred different analyses of everything from brain w'aves to blood metabolism; I repeatedly sec physicians running three or four hundred dollars' worth of tests in a vain attempt to find out what’s wrong with one sick boy. The trouble with this procedure never lies in the tests themselves—they are a valuable and often indispensable aid to better diagnosis, if the doctor uses them instead of letting them use him. No, the trouble lies with the kind of doctor who makes tests first and observes the sick human being he's treating second. When I think of this failing, which is every day more common. I think of a small boy who was sent to me not long ago because he was bleeding persistently from the rectum. He had been Xrayed; he had undergone chemical analyses of various kinds; he had been put through every test imaginable except the simple rectal examination that revealed a big polyp, the growdh that was causing the bleeding. Once it was located it was easily removed, and the bleeding ended, fortunately, before the boy was seriously harmed.
IN AN EMERGENCY, YOU ACT FIRST AND TEST SECOND
Again. I’ve seen otherwise intelligent young doctors postpone urgently needed treatment until laboratory reports came through. One, in charge of a child suspected of harboring an active case of diphtheria, told me, "I’m waiting for the bacteriological report.’’ In the twenty-four hours it takes to complete a bacteriological report the child might have died. Any doctor who trained before the era of proliferating laboratory analyses could have told this young man that when you suspect diphtheria you give antitoxin first, and test second. Another child. I learned after the event, lay in a diabetic coma while his doctor waited for a lab report to tell him exactly how much fluid the child needed to restore his blood-sugar balance. But for the intervention of an older doctor it might have led to serious consequences. Again when you are dealing with a diabetic coma you inject at least some fluid first, and test second.
What makes ovcrreliance on tests and analyses doubly troubling is that the doctors who tend to look at lab reports before they look closely at sick human beings are often the best of the young doctors in other ways—the brilliant young scientific specialists whose extensive and intensive training has somehow missed the precious apprenticeship of intimate contact with the patient and all his problems. Lately, they have had a new set of accomplices: the very patients they are trying to cure. The public has come to expect a battery of tests every time they see a doctor, and to put more faith in uninterpreted scientific evidence than in the judgment of the man who is trained to treat them. Some patients with a smattering of medical knowledge or
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One diagnostic genius predicted the death of a president at a glance — six months in advance
an overdose of anxiety will insist on tests. They’ll say, "Doctor. I want an X ray.” “What of?” “I don't know. you’re the doctor." Since my patients' mothers are thirty years younger than 1 am, it's easy for me to say no, but it's hard for a young doctor to assert his authority over an executive twenty years his senior.
For all these reasons, some doctors today are losing sight of the fact that clinical acumen, which is a quality of the individual doctor and can't be acquired by everyone, still lies at the core of the diagnostic process. Fifty years ago, when I was a medical student, our five senses plus intelligence were almost our only means of arriving at a correct explanation of the patient’s complaints. We could examine the urine or the sputum in a primitive manner; we would have an ill-equipped and grossly limited bacteriological laboratory test some of the patient’s secretions and we might occasionally order an X ray taken on a cumbersome apparatus, recently invented and not in general use by physicians. As late as 1920 the worldfamous Babies Hospital in New York, where I was in training, had no X-ray machine and a child had to be sent by cab to another hospital if the professor wasn’t quite sure whether there was fluid in the child's chest. The glass plates, heavy, fragile and often inconclusive, were delivered next day.
In those days we w'ere surrounded by ignorance and most physicians groped in the dark and guessed wrong a good deal of the time. But even then medical geniuses like Osier were able to leap over diagnostic hurdles with no aids but their own experience, their keen eyes, willing ears and sharp wits.
How did they do it? Why, today as yesterday, are some men better than others at diagnosis? When the same report means different things to different doctors, why is one more likely to be right than another? To begin with, there’s a God-given spark
that can be developed by training but can't be taught if it’s not there. Why is one man an athlete, another a musician? You can train till the cows come home and you won't be Paderewski or Roger Bannister.
When I first came to the Montreal Children's Hospital forty years ago 1 worked under a born diagnostician. Dr. Harold B. Cushing of McGill. This quiet man was a legend in his day. the doctor's doctor who after all available laboratory aids had been ex-
hausted would often solve the most abstruse problems by the sheer magic of his intellect. A tiny spot on the skin, the particular color or distribution of a rash, the mere tilt of the patient's head, and quizzically, almost apologetically, Cushing would ask. “Isn't it such and such?“ and he would be right.
Another diagnostic genius was Dr. Emanuel Libman, whose patients included Einstein, Lord Northcliffe and Sarah Bernhardt. The faintest tremor
of a hand, the manner of a walk, clues invisible to anyone else would give him the diagnosis in an instant. Once, watching President Warren Harding address a dinner meeting in New York, Libman remarked. “That man will die in less than six months.” It was just about six months later that Harding died in office.
No one has ever equaled Libman’s extraordinary perception, though some patients expect miracles. I once disappointed a woman w'ho brought her
little boy for examination. Atter I told her what was wrong with him she said flatly, "I’m not satisfied. They told me you'd only look at the child and you made him undress completely.”
To a doctor's innate talent for diagnosis must be added observation, which is purely a matter of training. The teaching of medicine is. or should be, teaching to observe. In an examination, I used to ask students, "What is the best method of administering fluid to an infant?" They'd discuss intravenous injection and other complicated techniques and miss the obvious answer every mother knows: by the mouth. You learn to notice tiny, apparently insignificant details. A child coughs at night; does he sleep with a teddy bear or a blanket like the little boy in Peanuts? Another has asthma attacks only on Fridays; is he allergic to fish? A baby has a mysterious attack that looks like mercury poisoning; has his mother broken a thermometer on the floor of his playroom?
Diagnostic ability depends not on some magical sixth sense but on the complete use of all your senses. You acquire it by constantly seeing people until it becomes as automatic as driving a car. 'Prying to explain this faculty that can't he described in words, a brilliant pathologist once said. "I knowmy uncle, but I have no way of telling you which man in a crowd is my uncle until you've seen him three or four times and can recognize him yourself. In the same way I can tell you whether or not a growth is malignant, but I can't always tell you why.”
I remember a child who came into hospital dangerously ill. Dr. Cushing looked at him and felt his abdomen and knew’ he had peritonitis and they operated. A young doctor said, “My God, how did you know?” He just knew.
This is the intuition that tells you what to look for in laboratory reports and how far you can trust the results of tests. An experienced doctor will sometimes tell a laboratory technician, “That figure must be wrong. Will you run it through again?” or, “I think your solutions are coming through too high." Three days later the laboratory is liable to report that the solution w'as wrong. Laboratory technicians are as human as doctors, and just as likely to make mistakes.
Laboratory reports can mislead a physician if he doesn't know' his patient well. If a boy's urinalysis shows albumin, he may have kidney disease or he may only have been taking exercise such as football or even a brisk walk. Sugar in urine is equally deceptive. It may be a temporary irregularity in some conditions or it may just mean that the specimen has come in a bottle whose cap still bears traces of some syrupy medicine. Two aspirin tablets will give an appearance of sugar in urinalysis. I once mistakenly diagnosed diabetes in a boy who was breathing heavily and whose urine gave the reaction we usually interpret as sugar. I rushed him into hospital where a young intern gleefully pointed out that he had not got diabetes but mild aspirin poisoning. 1 missed this important diagnosis by neglecting to ask a simple question.
Unless a doctor has some idea of what he's looking for. his tests may be wasted. There are times when a blood
test may not reveal leukemia which may yet be suggested by an astute radiologist from characteristic bone changes. A stethoscope may pick up lung trouble that doesn't yet show on X rays. An X ray can't hear a heart murmur and an electrocardiogram can't always report whether or not a heart is normal. Each test has its limits and none is infallible. Even the blanket approach doesn't always work because some conditions just aren't revealed by laboratory methods. Few tests tell much about rheumatic fever, for instance. What a doctor sees anil hears is still the most important gauge of things that aren't yet susceptible to measurement.
There’s no clinical test for wackiness. Once a boy of fifteen came into my office on crutches, one leg bound in a huge bandage. His doctor suspected rheumatism and the boy had had X rays and every kind of medicine. He hadn't put his foot to the ground for three months. When I stripped oil the bandage I found a 11 movements present, all reflexes normal, no swelling. yet he said the leg was painful. I thought for a minute, then said, "I think I can cure you." I did some hocus-pocus massage and asked him to try to walk. He took a step or two and stumbled. I worked on him again, all by suggestion, and soon he was hobbling across the floor. To satisfy my dramatic sense I asked him to walk to his mother in the next room, his crutches held high. That boy didn't need bandages and X rays; he needed help, perhaps from a psychiatrist. By talking tohim I discovered that he had had a'violent quarrel w ith his teacher three months before and to avoid going to school had taken refuge. not quite consciously, in his mysterious illness.
I remember a smaller boy who was subjected to a battery of hospital tests after he suddenly lost his voice. The doctors had talked to his mother but no one had interviewed the child. Yet. after a word of reassurance his voice returned. Ten minutes alone with him revealed that another boy in his class had done something mischievous and he was the only one who knew the culprit. What simpler way of not tattling than to lose your voice?
The only way a doctor can track down these ailments and a good many others is by talking to the patient, literally making him tell what's wrong with him. This kind of history, which was at one time almost all a doctor had to go on, is still a key source of information which he must sort out and interpret before he begins laboratory tests. He needs tact and perception to deal with people who may hide, exaggerate or forget their symptoms. Some disturbed patients manufacture answers from the depths of their delusions, and some people can't tell you anything. As a pediatrician, I'm used to patients who can't talk. A mother's impression of what's wrong with her child is emotionally colored and often w'rong. and the baby can't say. As Stephen Leacock once said to me, it's like being a veterinary.
It's often genuinely impossible to make a diagnosis, even after autopsy. Nevertheless a doctor is more likely to fathom a person's trouble if he has some idea of what that person is like. I bis is where the mill clinic is wrong. I have a great objection to the assembly-line technique in which patients arc run through a series of tests, some appropriate, some superfluous, all expensive. Once, in a big hospital in the United States. I accompanied a doctor on what has come facetiously to be called his "chart rounds." a daily examination not of patients but of reports hung outside their doors. He had their statistics at his fingertips but scarcely knew their faces.
It's difficult for a big hospital, geared to emergencies and desperate illness, with all its brilliant brains and modern equipment, to realize that an apparently obscure case can be something so commonplace they just haven't thought of it. The entire stall of a Montreal hospital was baffled by a girl who developed a high fever every evening. Consultants from other hospitals were called in to suggest Malta fever, typhoid and other rare diseases which were eliminated one by one. Then a bright nurse, noticing that the girl asked for a hot water bottle every night, discovered that she was faking the fever by holding the thermometer against the bottle.
I've seen a Jewish hospital miss an obvious case ol" trichinosis, a girl with typical fever, blood count and swollen eyes, because trichinosis is associated with pork. Another hospital kept two Eskimo boys for weeks, not suspecting the same disease until a parasitologist told them that trichinosis is common among Eskimo, who can contract it by eating the raw meat of fox or polar bear or any carnivorous animal.
It takes a heap of imagination to diagnose the thing that's unlikely but ordinary: scurvy in a child who refuses orange juice, malnutrition or pellagra in a prosperous suburb, some common tropical ailment transported to our cold country. A young doctor, fresh from years of training, just doesn't expect the simple things. Unconsciously he thinks, ‘Tm a big man now: nobody's going to come to me with a cold in the head: they must have something and I’m going to lind it."
Doctors were just as pompous in the old days. I must admit. One fashionable physician, who drove around Montreal in a great Pierce Arrow', never bothered to undress a child for examination. Early one morning one of his patients called me to say that she couldn't reach him: would I come to her baby who seemed to be choking to death? I ran all the way. found the child gasping for breath and shoved my finger into his throat to let out the abscess that was choking him. His mother told me that the doctor, visiting him daily, had diagnosed an enlarged thymus, a medical misconception popular at that time. As ethics demanded, I called to tell him what I had done and he said. “The abscess wasn't there yesterday. Did you know that child has an enlarged thymus?" I murmured something noncommittal. In all seriousness he said, expansively. "You know, I believe you and I are the only doctors in Montreal who would have made that diagnosis."
No one can help rejoicing that medicine is becoming more and more scientific. Today diagnosis is ten times easier and a thousand times more accurate because we have these ancillary tests working for us. The laboratory is largely responsible for saving thousands of babies who wouldn't have survived forty years ago. Only tests can forestall a blood transfusion that might be fatal, or determine the exact amounts of fluids and mineral salts needed by an infant ravaged by diarrhea. Even if there's no treatment for the thing you suspect, as is still the case with most virus diseases, you have to pin it down as closely as you can in case someone comes out with a remedy. The day before insulin was discovered, diabetes was an unbeatable disease. And tests are necessary to exclude possibilities as well as reveal them. So long as they’re done with a purpose and not indiscriminately. they are justified.
We older doctors welcome any help science can give us, but we hope it won't crowd the art out of medicine altogether. The science of medicine can be learned from books; the art can only be absorbed through one’s skin. Humanity and seasoned judgment still have a place in a profession whose business is not investigation for its own sake but simply finding what is wrong with sick people and helping them to get well. ★