Are You a Great Diagnostician?

Batya Swift Yasgur, MA, LMSW

March 27, 2013

Introduction

A majority of doctors think they have it; very few will say that they don't have it. And many are happy that they're "good enough."

The epithet is "great diagnostician." It's the doctor who, when confronted with a patient whose condition doesn't seem to have an obvious diagnosis, suspects what the disease or ailment might be or can point testing in the right direction. Or who recognizes potential signs of an uncommon disease that many doctors have never seen and don't think of. It's the doctor who simultaneously thinks of both horses and zebras.

"Great diagnosticians recognize that even the 'simplest' cases might turn out to be complex, and that sometimes the most 'complex' presentations might have a simple explanation," says Alan Katz, MD, Cardiologist, Cardiac Imaging Department, St. Francis Hospital, Roslyn, New York, and Vice President of Medical Informatics at Catholic Health Services of Long Island. The trick is to "bring experience and freshness to every case, and avoid thinking in black and white."

Every Doctor Is Not Equal

Are there really categories of good, better, and best diagnostician? And how important is it to be in "the best" category?

It's critically important, according to patients as well as physicians. Patients, of course, want to be rid of what ails them and are waiting for the physician to ferret out clues and pull the correct diagnosis out of a hat with a triumphant flourish, bringing clarity and solutions to troublesome or dangerous health problems.

But for doctors, finding a difficult condition is rarely an epiphany in which the answer shoots up in a burst of fireworks. It's a combination of many things, including a solid knowledge base, good listening skills, ordering the right tests and interpreting them correctly, performing a skillful examination, and -- perhaps most important -- thinking creatively.

Some of today's physicians are falling short in these qualities, according to a just-published medical record review of 212,165 patient visits at 2 major primary care facilities.^[1]

The researchers found 190 cases of diagnostic errors that "had potential for moderate to severe harm." Worse, these diseases were not exotic "zebras," but instead were run-of-the-mill "horses," such as pneumonia, congestive heart failure, acute renal failure, primary cancer, and urinary tract infection. The researchers attributed most errors to "patient-practitioner clinical encounter-related processes, such as taking medical histories, performing physical examinations, and ordering tests."

This leaves both patients and physicians in trouble. Patient health is compromised. And physicians face potential legal complications, because failure to diagnose is one of the most common causes of medical malpractice lawsuits.

Beyond avoiding litigation, being a good diagnostician has another advantage: It builds your practice. A good diagnostician's waiting room is crammed with patients who've been on the waiting list for weeks or even months but won't see anyone else.