Doctor As Detective

Dr Jitendra IngoleMD Internal Medicine Associate Professor, SKNMC & GH, Pune

Diagnosis …Art or Science ?Best answer would be a judicial combination of both. History & Clinical examination are paramount importance. For they provide foundation for planning out investigations or treatment.

Doctor as detective

White Coats and finger printsIsn’t much of a doctor’s work alike to

that of a detective?

Current scenario Routine use of sophisticated diagnostic tools is killing the art of clinical reasoning. Blind faith in technologyPre determined diagnostic algorithms

How to confront the problems posed by burgeoning number of available technologies….

The need of hour is ……Harmonic fusion of all investigative methods of fictional detectives. Avoid slavish adherence to protocols.

What is happening today is……Burn money to make diagnostic work up superficial Losing intellectual pleasure that comes from careful diagnostic reasoning.

Remember…….An investigation, however sophisticated and expensive, if performed inappropriate clinical settings, will be useless.

Some analogies between detective and clinical methods

Try to restore status quo undermined by crime or disease Thrive on climate of faith in capabilities of science and base their methods on interpretation of clues and s/s. Reach final conclusion by decoding signs and symptoms often meaning less to layman.

What Sherlock Holmes said……..Qualities Of Ideal Detective

Qualities of Ideal Detective…..Observation

Deduction

Knowledge

Shared qualities of detectives & Clinicians

Ability in Observation Ability in Deduction Knowledge Ability to reconstruct psychological & social profile Ability to spot inconsistencies

Observation & reasoning…..Three qualities

Deduction

Induction

Abduction

General to particular

Particular to general

Forming an explanatory

hypothesis Not only presence of evidence but also their absence is important.

So, here is the flaw…..Flawed belief that disease can be diagnosed accurately from its specific external signs

And Lo Behold……We are taught similar way from UG days…. Only to learn hard fact later, that signs/symptoms may not follow books. Overcoming the blind faith is very important.

Knowledge

General knowledge Mental Archive of Past cases

KnowledgeThere comes a time, when for every addition, there is deletion of previous knowledge from our memory.

So……..It is important to know what is important & what’s not. And do not allow useless to replace useful knowledge.

I have internet connection……hence I am invincible doctor….because I have every possible answer in the world.

The Armchair Specialist…? Having access to knowledge does not mean that it will be utilised accurately. Net searches are worth if & only if clinician conserves his bedside role.

Reconstruct Psychological Profile

“ Are you investigating murderer (Disease)

or Victim (Patient). ”

A detective says ……“ I will identify murderer when I fully know

victim. ”

A doctor says …..“ I will identify the disease when I

fully know patient. ”

Ability to Recognise Inconsistencies

Normal or low voltage ECG, HOCM

Cardiac Amyloidosis

Sherlock Holmes Aphorisms……You see but you do not observe.

My method is founded upon observation of trifles.

Never trust general impressions, but concentrate on

details.

It is capital mistake to theorise before one has the data.

Sherlock Holmes Aphorisms……There is nothing like first hand evidence.

There is nothing more deceptive than an obvious fact.

The world is full of obvious things which nobody by any chance observes.

When you have eliminated all impossible, whatever remain, however improbable, must be the truth.

And the punch line is …….

Do not try to twist the facts to suit theories. Rather, theories should suit the facts.

Adherence to protocols and procedures……

Though guidelines raise average quality of care, but if applied uncritically and blindly, can cause pitfalls.

Thus the need of hour is…….Proper and Juridical use of clinical or treatment guidelines.

Take Home Message is …….

Clinical method as science and art of investigation

Mature ClinicianSpot inconsistencies among clinical , instrumental and lab examConsider not only what is present but also what is missing. Capacity to establish links – physical lab., instrumental finding.Simple logical clinical exam has same value as complex expensive investigation.

Doctors, Detectives and common sense

How detective like approach can help to doctors to make diagnosis ?

The lady detective….Mma Ramotswe

Waiting to see doctor for about an hour outside his consulting room

Makes accurate & intelligent observations…which then she narrates to doctor

First patient was butcher……How ?

Lost a finger on his left hand Scratching his body

Second female patient unable to sleep at night…… How ?

Slept off while waitingHad to be awakened on her turn Milk stains on her clothes… must have been awake due to baby

Third female patient….UnhappyUnhappy but not depressed……Because she was continuously knitting and was busy which a depressed person can not do.

And then, her doctor tells detective not to eat too much doughnuts…….How ?

Because her weight not decreasing since last few years. Sugar in front of her dress which was spilled from doughnuts.

The Message is clear…….In other words, history taking and clinical examination should not become too structured ritual.

Think And Act……It also means to have a clear systematic approach in mind whether taking history or doing clinical examination.

Thanks