"It is clear that physicians take widely different attitudes towards investigations, some relying on them much more heavily than others."
– J.R. Hampton, et al., British Medical Journal, May 31, 1975
In 1975, a study was published in the British Medical Journal looking at new patients referred to a medical clinic. The study looked specifically at how a diagnosis was made for each new patient, and it concluded that in 66 out of 80 patients, a diagnosis was arrived at based on the history alone, that the physical exam was useful in an additional 7 patients, and that lab testing was useful in the last 7 patients (Br. Med. J. 1975;2:486-9). Since then, medical students have been taught that a good history will lead to the diagnosis about 80% of the time.
One of my professors in my internal medicine class taught me this aphorism. I thought he was brilliant. Surely, anyone who can come up with a diagnosis just by talking to a patient is a minor god? (He is a rheumatologist. He became my mentor, and is, in fact, one of the major influences in my choice of specialty.)
Medical school in the Philippines forces one to think that way anyhow. There is very little government-provided health care; everything else is paid for out of pocket. This means that every CBC I order, every electrolyte panel, every antinuclear antibody, every urinalysis, is charged to the patient. There are not enough hospital beds, ventilators, or MRI machines.
So patients waited a while before seeking medical attention, which means we took full advantage of a history that’s remarkably evolved, with classic, textbook physical exam findings. The general medicine wards were crammed with patients with jaundice, whether from hepatitis or from having the carcass of a dead ascaris worm lodged in their bile ducts. We saw fungating breast masses. Hyperthyroidism is not that hard to identify when the patient is in frank thyrotoxicosis. Patients with pulmonary tuberculosis had massive hemoptysis, buckets of blood, and acid-fast bacilli in the emergency department.
This is the environment in which I trained. Could I say then that I would be able to identify a problem just from taking a history alone? If you had months’, nay, years’ worth of history to work with, you’d be able to identify the problem, too. I’ll bet doctors who practiced in the 1960s and 1970s in the United States had similar experiences, having the benefit of witnessing full-blown cases of anything and everything.
Do I practice this way now? Not at all.
But that isn’t to say I don’t take a good enough history or physical exam, it’s just that patients seek medical attention earlier, and we have so many more resources at our disposal. We have the ability to detect illness before it wreaks havoc. (There are other, less charitable interpretations of this behavior, such as lack of time, patient expectations, etc. But that’s a topic for another time.)
I have a great deal of respect for my mentors who practice with very real limitations. I have no doubt they are better doctors than I am. And, of course, I feel nostalgic for the way we used to do things. It is easy to romanticize the sepia-toned snapshots of my third-world youth. But really, modernity is a blessing. We should celebrate our ability to find things early. Nostalgia is for meals and memories. Medicine is much more pedestrian than that.
Dr. Chan practices rheumatology in Pawtucket, R.I.