The Art of Diagnosis: Getting to the Root of Complex Medical Problems

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Presented by: Bryant Lin, MD
Clinical Assistant Professor, Medicine – General Medical Disciplines
Stanford University School of Medicine
February 6, 2014

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Even in this age of modern medicine, doctors can’t always crack the case. Some patients have an illness or disease that defies a simple diagnosis. Those are the people for whom Bryant Lin, MD, has opened a new clinic at Stanford University School of Medicine.

The Consultative Medicine Clinic at Stanford is the only place on the West Coast that specializes in the complex diagnosis of patients who have seen multiple doctors without getting an explanation for their illness, Lin said. He takes inspiration from a legendary figure who was the model for Sherlock Holmes, the fictional British detective who could always solve a crime that stumped police. Holmes was famous for his ability to deduce the culprit based on observations and clues that others overlooked.

Doctors diagnosing a complicated case of illness can resemble detectives working to solve a mystery, Lin told an audience at a presentation on complex diagnoses sponsored by the Stanford Health Library. The author who created the Holmes character, Sir Arthur Conan Doyle, was a physician in 19th century Great Britain. Doyle based the character on a Scottish physician and lecturer named Joseph Bell, who was famed for his powers of observation in patients.

“Bell took pride in his ability to observe patients and being able to figure out what was going on with them, just from observing,” said Lin, clinical assistant professor of medicine at Stanford and medical director of the Consultative Medicine Clinic.

If Bell was the model for Sherlock Holmes in 19th century Britain, both these icons have spawned cultural descendants for the 21st century. The most recent is the bearded antihero doctor on the TV show known as “House.”

“He’s a crotchety drug-addicted … diagnostician,” said Lin. “A lot of people say Sherlock Holmes was the inspiration for him.” The TV show departs from reality in multiple ways, with House’s team of three physicians acting like they can do the work of 10 to 15 medical specialists. And House just studies patient data to figure out what’s going on and “tries all these crazy things,” Lin said. “That’s obviously unlikely to be the case.”

Yet the TV show – and the Holmes character – illustrate one crucial part of a doctor’s work: diagnosing a complicated medical case can take a lot of painstaking medical observation and examination, Lin said. An important part of this is spending time to talk to a patient and get a good medical history and physical exam – something that Lin is able to do in the Consultative Medicine Clinic. “This is really the cornerstone of diagnosis of many things – most things – in medicine,” Lin said.

The history of medicine shows that doctors have studied the power of observation and deduction to get a good diagnosis since ancient times, Lin said. One of the earliest written texts in medicine was a 1500 B.C. Babylonian description of military surgery done in 48 cases of injuries. The text recorded the observations and medical trials to see what worked – along with a list of four magical spells for treatments. Notwithstanding the fallacy of the spells, that showed even ancient doctors tried to develop a standard thoughtful method of diagnosis.

Hippocrates, the ancient Greek physician known as the father of modern medicine, was thought to be the first person to believe that diseases had natural causes rather originating from superstitutions, Lin said. Hippocrates was the first to observe that people with clubbed fingers also had symptoms linked to what we now know as chronically low oxygen caused by heart or lung disease. “That’s an observation connected to disease,” Lin said.

During the Middle Ages in Europe, as plague became widespread, medical practitioners known as “plague doctors” espoused the notion that the plague was spread by “humours” in the air, Lin said. Unfortunately, such humours were never identified, so treatment relied on futile efforts such as bloodletting with leeches or frogs to “rebalance” the humours.

Eventually, scientists developed more rational explanations for disease and illness. With that came medical instruments that could measure conditions including blood pressure, heart rate and rhythm, body temperature and more. The first stethoscope was invented in 1816 by a French physician, Rene Laennec, who listened to a patient’s heartbeat using a hollow tube of wood. In 1895, Wilhelm Conrad Roentgen discovered that x-rays could produce images of internal bones. The first practical electrocardiogram (or EKG) was developed in 1903 to measure the electrical activity of heart muscle.

By the 1950s and 1960s, Lin said, doctors could choose any of about 10 laboratory tests to help diagnose illness in a patient. Modern medicine now has many more medical tests, including angiograms, ultrasounds, numerous pathology tests, and imaging tests known as MRI (for magnetic resonance imaging), CT (for computed tomography), and more.

With a complex diagnosis, doctors don’t always get the answer right. Or they don’t even get an answer. “There is still a lot we don’t know,” Lin said. “We don’t have complete knowledge of every disease.”

It’s also difficult for doctors to spend more than the 15 to 20 minutes allotted for most patient visits to get a good diagnosis. At the Consultative Medical Clinic, Lin is able to spend an hour to 90 minutes for a first visit when a patient is referred by other physicians for a complicated condition.

“We’ve made a lot of progress,” he said. “But we’re still dependent on taking a good history.”
Lin doesn’t plan to lose sight of that core value in medical care, even if he does take advantage of some very 21st century developments to update the old-fashioned need to observe and deduce.

He plans to incorporate “decision-support software” to generate some possible differential diagnoses for patients with complex illnesses. He may also tap a variety of medical databases now online that draw from scientific literature in medical journals, on PubMed, and other Internet sources.

He’s also starting a research study soon to evaluate the usefulness of an online social network created to help doctors discuss difficult medical cases. That puts a new spin on the old practice of doctors consulting their medical colleagues for advice when they’re stumped.

Putting the network online, he said, “really helps to have that interaction.”

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