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DELAYS AND SUPS IN MEDICAL DIAGNOSIS fOEL E. DIMSDALE* That doctors make mistakes in medical diagnosis is hardly a startling revelation. Assessing the patient with interviews, physical examinations, and laboratory tests is a complicated process; many factors may hinder making an accurate diagnosis. When the process is delayed or when misdiagnosis occurs, one tends to blame the complexity of the disease itself, the physician's inadequate knowledge, or the lack of a readily available decision-making model. There is, however, an additional set of factors which may obstruct accurate diagnosis; these factors relate to die physician's feelings about the patient, his behavior, or his disease. It is the thesis of this paper that certain physician-patient interactions are so prone to conflict that the physician may miss a diagnosis that is crystal clear to another observer. To illustrate this process, I will be referring to three case histories. I am not writing about cases in which there is in retrospect diagnostic ambiguity; instead, there is painful clarity to all of these cases of misdiagnosis. Similarly, I am not writing about the details of management (where there is always room for disagreement ), nor am I writing about the continuing care of difficult patients. The phenomenon that I would like to address direcdy is how eminently qualified physicians blind themselves to the extent that they miss a diagnosis that would be made readily by others. When one typically thinks of problems in medical diagnosis, the nature of the physician-patient relationship is not considered, but three other factors are considered—the history, the physical, and the laboratory findings. Obtaining a history is not straightforward. Medical interviewing is a difficult task, a skill whose importance is emphasized from the earliest days of medical training. Learning how to take a history This work was supported by a Clinician Scientist Award from die American Heart Association with funds contributed in part by the Massachusetts American Heart Association Affiliate. The author thanks Drs. Arthur Barsky, John Stoeckle, and Ed Messner for their advice and criticism. ?Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114.© 1984 by The University of Chicago. AU rights reserved. 0031-5982/84/2702-0378$01 .00 Perspectives inBiology and Mediane, 27, 2 · Winter 1984 \ 213 requires effort, patience, and tact as well as an organized, coherent framework for processing the information [1, 2]. Conducting the physical examination requires extensive training so that the findings may lead to accurate diagnosis. The distinctions, for instance, between a III/VI and IV/VI systolic murmur or between loose associations and flight of ideas are subtle ones that require substantial practice to master. The interpretation of laboratory tests is a problem not only of knowing what the tests mean [3] but also of knowing when they are used incorrectly. This problem was demonstrated unusually vividly in the care of President Garfield after he was shot. Garfield lingered months before dying because his physicians were unsure of the location of the bullet and feared that exploratory surgery would prove fatal. Alexander Graham Bell invented a metal detector for them and attempted to locate the bullet with this new invention [4]. The effort failed. On scanning the president, Bell observed a puzzlingly high level of interfering background noise which impeded the machine's performance; this was later attributed to the fact that the president had been studied while lying on an army cot with metal springs. Furthermore, Bell scanned only the right side of the president's back; at autopsy, the bullet was found on die left [5]. Thus, even the most advanced techniques are prone to failure when applied incorrectly. When operating smoothly, skillful interviews, physical examination, and interpretation of laboratory findings produce the diagnostic precision for which Western medicine isjustifiably acclaimed. For some, these skills are so finely sharpened that the diagnostic process becomes a competitive contest, the laurel going to him who makes the diagnosis widi the fewest bits of information. Because so few of us can be Queen Square neurologists in diagnostic acumen, most of our diagnoses are more pedestrian. We rely on all the information we can get, including new techniques of decision making and multivariate analyses [6-8...


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