Dr James Le Fanu: 15 November
During the past 30 years our bodies have become so transparent there is no nook or cranny that cannot be visualised in one way or the other, whether by the doctor peering down his endoscope or with CT scans that delineate the innermost recesses of the brain.
This technology should by rights have transformed the art of diagnosis, making it simpler and more accurate. Paradoxically, doctors today can be less adept than their predecessors at identifying what is wrong, as shown by the experience of an acquaintance in his mid-50s.
It all started with a nasty bout of flu. Then after a few days he woke with a stabbing chest pain and, fearing the worst, took himself off to casualty. There he had the usual tests including an ECG and a chest X-ray, which suggested he could have had a heart attack in the recent past, while the presence of some fluid on his lung could be due to a small tumour.
By now he was pretty apprehensive, but was given an appointment to see a specialist. By the time he returned as an outpatient 10 days later, his symptoms had all resolved. Nonetheless, the specialist recommended an ultrasound of the gallbladder (this revealed a single gallstone) and an endoscopy of the stomach, which was normal. He had thus acquired three possible diagnoses, two of which (the coronary and the lung tumour) proved to be incorrect while the third (the gallstone) was unrelated to his chest pain.
It might seem unfair to draw any general conclusions but this episode reflects important changes in the practice of medicine. Prior to endoscopies and CT scans, medical diagnosis was grounded in what was known as ‘clinical methods’, which required cross-examining patients about symptoms. This involved, for a complaint such as chest pain, inquiring what it felt like, what made it better or worse, how long it lasted, whether the patient had had it in the past and if so, when and how often. By the end of this process, and without ordering a single test, it is usually possible to infer with 90 per cent accuracy what is wrong.
How does this relate to my acquaintance’s experience? The history of a flu-like illness followed by sharp chest pains is strongly suggestive of inflammation either of the lungs (pleurisy) or heart (pericarditis) and both can be diagnosed on clinical grounds alone. All the doctor has to do is prescribe antiin flammatory drugs, with the reassurance that the pain will probably go within days.
It is difficult to give specific advice on how to avoid spurious diagnoses but a useful tip when investigations are proposed is to ask, ‘What difference will it make if I don’t have it?’ This should at least focus the doctor’s mind.
This week’s medical query comes from a lady in Lancaster who says that within minutes of standing at the ironing board or worktop she has numbness of the feet, which creeps up the legs into the buttocks, at which point she has to sit to avoid falling. ‘Once seated the numbness goes quickly,’ she writes. Exercises recommended by a physiotherapist have not helped. What is wrong?
It is almost certainly due to the narrowing of the vertebrae at the base of the spine, causing pressure on nerves, known as lumbar spinal stenosis. Best clarified by an MRI scan, treatment depends on exactly what is amiss, and may include antiinflammatory pills, epidurals or a ‘decompression surgery’.
Email drjames@lady.co.uk
This technology should by rights have transformed the art of diagnosis, making it simpler and more accurate. Paradoxically, doctors today can be less adept than their predecessors at identifying what is wrong, as shown by the experience of an acquaintance in his mid-50s.
It all started with a nasty bout of flu. Then after a few days he woke with a stabbing chest pain and, fearing the worst, took himself off to casualty. There he had the usual tests including an ECG and a chest X-ray, which suggested he could have had a heart attack in the recent past, while the presence of some fluid on his lung could be due to a small tumour.
By now he was pretty apprehensive, but was given an appointment to see a specialist. By the time he returned as an outpatient 10 days later, his symptoms had all resolved. Nonetheless, the specialist recommended an ultrasound of the gallbladder (this revealed a single gallstone) and an endoscopy of the stomach, which was normal. He had thus acquired three possible diagnoses, two of which (the coronary and the lung tumour) proved to be incorrect while the third (the gallstone) was unrelated to his chest pain.
It might seem unfair to draw any general conclusions but this episode reflects important changes in the practice of medicine. Prior to endoscopies and CT scans, medical diagnosis was grounded in what was known as ‘clinical methods’, which required cross-examining patients about symptoms. This involved, for a complaint such as chest pain, inquiring what it felt like, what made it better or worse, how long it lasted, whether the patient had had it in the past and if so, when and how often. By the end of this process, and without ordering a single test, it is usually possible to infer with 90 per cent accuracy what is wrong.
How does this relate to my acquaintance’s experience? The history of a flu-like illness followed by sharp chest pains is strongly suggestive of inflammation either of the lungs (pleurisy) or heart (pericarditis) and both can be diagnosed on clinical grounds alone. All the doctor has to do is prescribe antiin flammatory drugs, with the reassurance that the pain will probably go within days.
It is difficult to give specific advice on how to avoid spurious diagnoses but a useful tip when investigations are proposed is to ask, ‘What difference will it make if I don’t have it?’ This should at least focus the doctor’s mind.
This week’s medical query comes from a lady in Lancaster who says that within minutes of standing at the ironing board or worktop she has numbness of the feet, which creeps up the legs into the buttocks, at which point she has to sit to avoid falling. ‘Once seated the numbness goes quickly,’ she writes. Exercises recommended by a physiotherapist have not helped. What is wrong?
It is almost certainly due to the narrowing of the vertebrae at the base of the spine, causing pressure on nerves, known as lumbar spinal stenosis. Best clarified by an MRI scan, treatment depends on exactly what is amiss, and may include antiinflammatory pills, epidurals or a ‘decompression surgery’.
Email drjames@lady.co.uk