I read an interesting article this week in the British Medical Journal [1]. Penned by GP (family physician) Des Spence, it laments the over-reliance of doctors on sophisticated technological testing. There was a day, not so long ago, when the tests at a doctor’s disposal were relatively limited. This essentially forced doctors to rely more on their clinical skills to make diagnosis. My father once told me his own father (a doctor) maintained he made many diagnoses during home visits on the basis of the smell emanating from the home.
I utterly agree with Dr Spence, and regularly see patients who have been subjected to a barrage of tests, only for these and their doctors to draw a blank. Yet, my belief is that many if these cases could have been more effectively diagnosed and managed if there had been less reliance on testing, and more on the out-dated ‘arts’ of letting the patient tell their story and examination.
For example, a couple if months ago I saw a lady who had suffered a month-long headache. She had been referred to a private neurologist and been subjected to a battery if tests including MRI.
This woman complained of pain in the back of the head particularly the part of the skull that protrudes at the back. This sounded very much like muscular tension to me, and sure enough even a cursory examination confirmed this. She could not recall any doctor actually examining the part of her that was the site of her symptoms. If they had, she may have been spared unnecessary testing and concern. Her neurologist would be a little less well off, though.
This week I saw some with unexplained swelling in his legs. He had been admitted to hospital (privately, again) for comprehensive testing (all normal) and in the end had his knees injected with steroid. However, his knees were not the problem.
I asked if he was taking any medication, and he was. And it turns out a recognised side effect of the one medication he takes is swelling. He asked why no one had asked him about the medication he takes during his two-day stint in hospital. I expect it had something to do with his doctors’ over-reliance on tests.
I remember at medical school being taught by vastly experienced doctors that diagnoses can usually be made on the basis of what you hear and see, and that testing should mainly be for confirmation.
In reality, though, I think a lot of doctors expect testing to do the diagnosing for them. Dr Spence, in his column, writes,
Doctors are increasingly fearful of giving opinions even as “experts.” This is driving the increase in referrals that undermines the whole health system. Medicine is now bland, thoughtless, expensive, and indecisive. Opinion is the basis of all discussion and the catalyst of change. If you are unable or unwilling to give a measured opinion you aren’t functioning as a proper doctor.
In my opinion, the best doctors are not those supposed to be the brightest or best educated but those who recognise the limitations of medicine and can make a judgment. Expressing a medical opinion means we must accept being wrong occasionally and that opinions might upset others. Opinion is the art and craft of medicine; without it it would not be medicine at all.
I’d like to add an opinion of my own: Dr Spence is absolutely right.
References:
1. Spence D. What is the point of doctors? BMJ 2013;347:f7380
