‘First Do No Harm’ is a series of 12 brief monthly articles with internet footnotes about harming and healing in general practice. Each article is based on one of the 12 RCGP competency domains, this month’s being:
4. Making a diagnosis/making decisions: a conscious, structured approach to decision making.1
‘Skill in diagnosis and prognosis comes only with careful and continued schooling in observation; therapeutic achievement is seldom outstanding unless it be based upon accuracy in diagnosis, judgement in prognosis, and psychological insight, for all of which a proper understanding of the natural history of disease in man and of man in disease is a necessary equipment.’2
INTRODUCTION
Diagnosis can take many forms. It may be a matter of naming the disease, lesion, dysfunction, or disability. It may refer to management, prognosis, or risk. It may indicate either degree of abnormality on a continuum or kind of abnormality in a classification. It’s influenced by non-medical factors such as power, ethics, and financial incentives for patient or doctor. It can be a brief summation or an extensive formulation, even taking the form of a story or metaphor. How we choose, present, and act on the diagnosis can be pathogenic (making the patient more ill) or salutogenic (making them better). The diagnosis is generally uncertain and provisional.3 Diagnosis is not a single event but a process of reducing uncertainty about the nature of the patient’s condition.4
HARMING
Restricting the type of diagnosis, perhaps to either the biomechanical or the psychosocial. Fixing on the diagnosis too early and not refining it over time.3 Relying too much on rules1 and labels.5
HEALING
While developing rapport and collecting information, making hypotheses and refining them iteratively, often over serial consultations, using discretion, judgement, knowledge of probability, and time as a diagnostic tool.1 In all this complexity, giving the patient the single positive (albeit provisional) diagnosis6 that offers them in the circumstances the best outcome.7 Helping write another chapter in the patient’s book rather than trying to re-write the book.5
ATTITUDE
Trusting patient-centred consulting, examination skills, evidence-based medicine, and serial empiricism as the best available means of reducing uncertainty about diagnosis, prognosis, and management.3
KNOWLEDGE
Time-courses help in diagnosis and management: the natural history of diseases can be longer than we think.1 After apparently infectious intestinal disease in England odds of continuing symptoms at 3 weeks are around 1:4;8 after cough in pre-school children in England, odds of cough at 3 weeks are about 1:9;9 after cough in adults in Europe, odds of cough at 15 days are 1:1;10 after knee pain in adults in the Netherlands, odds of continuing pain at 12 months are 1:1.11 Many patients have no definite diagnosis at a first consultation and many of these patients do not re-attend.12
SKILLS
Using rules of thumb as short-cuts13 and lengthening the diagnostic process to safety-net.14 Thinking while washing hands slowly; looking something up while leaving the patient with a semi-automatic blood pressure machine; reflecting, discussing, and researching pending follow-up. Using the test of time.3
Supplementary information
The internet footnotes accompanying this article can be found at: http://www.darmipc.net/first-do-no-harm-footnotes.html
- © British Journal of General Practice 2012