I read an interesting article this week in the British Medical Journal [1]. Penned by GP (family physician) Des Spence, it laments the over-reliance of doctors on sophisticated technological testing. There was a day, not so long ago, when the tests at a doctor’s disposal were relatively limited. This essentially forced doctors to rely more on their clinical skills to make diagnosis. My father once told me his own father (a doctor) maintained he made many diagnoses during home visits on the basis of the smell emanating from the home.
I utterly agree with Dr Spence, and regularly see patients who have been subjected to a barrage of tests, only for these and their doctors to draw a blank. Yet, my belief is that many if these cases could have been more effectively diagnosed and managed if there had been less reliance on testing, and more on the out-dated ‘arts’ of letting the patient tell their story and examination.
For example, a couple if months ago I saw a lady who had suffered a month-long headache. She had been referred to a private neurologist and been subjected to a battery if tests including MRI.
This woman complained of pain in the back of the head particularly the part of the skull that protrudes at the back. This sounded very much like muscular tension to me, and sure enough even a cursory examination confirmed this. She could not recall any doctor actually examining the part of her that was the site of her symptoms. If they had, she may have been spared unnecessary testing and concern. Her neurologist would be a little less well off, though.
This week I saw some with unexplained swelling in his legs. He had been admitted to hospital (privately, again) for comprehensive testing (all normal) and in the end had his knees injected with steroid. However, his knees were not the problem.
I asked if he was taking any medication, and he was. And it turns out a recognised side effect of the one medication he takes is swelling. He asked why no one had asked him about the medication he takes during his two-day stint in hospital. I expect it had something to do with his doctors’ over-reliance on tests.
I remember at medical school being taught by vastly experienced doctors that diagnoses can usually be made on the basis of what you hear and see, and that testing should mainly be for confirmation.
In reality, though, I think a lot of doctors expect testing to do the diagnosing for them. Dr Spence, in his column, writes,
Doctors are increasingly fearful of giving opinions even as “experts.” This is driving the increase in referrals that undermines the whole health system. Medicine is now bland, thoughtless, expensive, and indecisive. Opinion is the basis of all discussion and the catalyst of change. If you are unable or unwilling to give a measured opinion you aren’t functioning as a proper doctor.
In my opinion, the best doctors are not those supposed to be the brightest or best educated but those who recognise the limitations of medicine and can make a judgment. Expressing a medical opinion means we must accept being wrong occasionally and that opinions might upset others. Opinion is the art and craft of medicine; without it it would not be medicine at all.
I’d like to add an opinion of my own: Dr Spence is absolutely right.
References:
1. Spence D. What is the point of doctors? BMJ 2013;347:f7380
In my experience, GPs do not want to touch their patients. For my cousin, this could have proved fatal. He went through months of tests with no results, and it was a hands-on consultation with an alternative practitioner that revealed a highly enlarged spleen. He was sent straight back to his GP where he was found to have leukaemia.
John, I too agree completely. Also that to have an opinion is to be wrong occasionally. And the generation of practitioners recently out of university appear to “do tests”. The client is uninsured and impecunious… Now what, test-wise? Arghhhh. Listening to owners can be remarkably effective in achieving a reasonable diagnosis even if confirmation is impossible.
Peter
PS it would be nice if Des Spence would do some more blogging. Can’t always agree with him but his posts are always interesting. A relief to see he is still actively polemical off blog.
In support of the aricle discussed, why do I find the GPs in the Practice I attend facing a computer displaying my ‘data’ rather than looking at me during the standard 8 minute consultation? Why was my last appointment conducted by a GP who spent some of the time looking up symptoms on Google? Walking into a surgery to talk to a doctor who is ,at best sitting at 90 degrees to the patient throughout the consultation (and on some occasions have their desks and chairs set up so their backs are to the door as it is opened), is surely a telling indication of where some GPs now look for diagnostic guidance?
Dear Dr. Briffa, I totally agree with this point of view. My father, a physician himself, worked for many years as a missionary doctor in India, Africa, Peru, Ecuador and Uruguay. I was a child at the time but, when home during holiday time, I was always following my father in the wards or sitting in a corner of wherever he attended to patients. There very few tests at that time, I can assure you. The very, very basics. Well, but my father had what was called “the clinical eye”. Amazing, in many occasions. Well,about 40 years later, I developed a weird condition regarding the production of platelets which was not very well known about here, in Uruguay. So some American friends invited me to go to the Norris Cotton Cancer Research Centre in New Hampshire. And there I saw this issue you mention. The doctors put me through a battery of tests – some rather horrid, such as removing a sample of bone marrow – and all for nothing. With the passing of time, and personal observation, I ended up realising I was a kind of allergy to certain chemicals. I used to work for Imperial Chemicals at the time. After changing jobs to something less hazardous, end of the problem. So nowadays, if a physician I visit starts chucking lab test orders at me, I know he is not very good or relies too much on technology. Good you brought this up since there seem to be too many people that if they are not issued half a dozen tests they seem to feel the doctor is no good.
Hi Dr John, I wholeheartedly agree and am willing to share my recent experience if only to help, or prevent, someone else suffering what I went through.
In November 2011, after my GP repeatedly denied a vitamin D test, I paid City Assays to discover my 25-hydroxyvitamin D3 was just 31.8 nmols/L (recommended range 75-125 nmols/L). I was also complaining of Paresthesia of the hands and was taken to A+E for anxiety, panic attacks and Dyspnoea. Because all blood tests showed everything was within their respective parameters I was clinically discharged with no further review.
Thankfully a Haematologist friend pointed to my serum B12 and Ferritin levels, though within range, would have been treated as sub-clinically low in the USA. My B12 was 348 ng/L (range 189-883) and Ferritin was 55 ug/L (range 22-275).
I think the recent media coverage of Alzheimer’s has something to do with recognising the B12 lower level should be raised in line with the Japanese level of 550 ng/L, together with Pfizers withdrawing their R&D for an Alzheimer drug?
Once I started to replete levels I began to research and discovered the anticonvulsants I had been taking for 44 years were responsible for eroding the body’s supplies of vitamins and minerals. I will add that Phenytoin also suppresses conversion of T4 > T3 of the thyroid. I brought my TSH down, from 4.8, to below 2.0 with Selenium.
I was then referred to an NHS Rheumatologist for possible Raynauds, or Carpal Tunnel Syndrome, that may have been causing the tingling in the hands. Then a Neurologist wanted to withdraw the Phenytoin as it is known to cause Peripheral Neuropathy. I was not convinced and paid privately again for a comprehensive parasitology test that proved positive for H-Pylori and Cryptosporidium and by using Caprylic Acid, Spirulina/Chlorella and high dose vitamin C, as antifungals the tingling has been resolved.
The GP did offer triple antibiotic treatment but I said that it would again unbalance the gut-flora and repeat previous problems.
So much expense and time can be avoided if only holistic, or allopathic treatment was reintroduced. But when our taxes and NI contributions are funding Big Pharma’s vested interest in medical schools what can we do?
To end with, once I ramped my vitamin D levels up I experienced chest pain. For some unknown reason common sense kicked in and, instead of thinking about a heart attack, I believed the replete vitamin D was interacting against the toxic Prozac I had been prescribed for 12 years. We need to heed Dr David Tanton’s view that no one is drug deficient.
If I had the opportunity with knowledgeable Doctors available I would like to substitute my anticonvulsants for the B vitamins and Magnesium to see if their deficiencies are the cause of my seizures.
Well, I hope my contribution will help others to try other options than keep relying on pharmaceutical drugs.
Kind regards, Will
I believe this situation has come about as a result of our litigious culture. I always feel as though the GPs are more concerned about covering themselves legally than they are with my welfare.
I studied Microbiology and Pathology for my science degree. I therefore spent more university hours studying microbiology than any GP, but GPs are considered to be more able to make a clinical diagnosis. I repeatedly find them relying on tests for intestinal pathogens that are inadequate at best, resulting in many patients suffering needlessly and acquiring a ridiculous number of different diagnoses.
There are a large number of doctors who seem unable to recognise that the possibility of any one patient having multiple different chronic illnesses at a fairly young age is very remote. The dependence on testing is so complete, that if the patient is clearly very ill but no tests confirm anything, the patient is either labelled as a pyschiatric case or is given “waste basket” diagnoses, like chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia and even rheumatoid arthritis in the absence of rheumatoid factor on testing.
No wonder so many are defecting to natural therapists…a minefield of ineptitude, yet currently appearing to have the upper hand in getting patients well. GPs are woefully uneducated in the area of nutrition, often missing basic nutritional deficiency pathology, as well as food intolerance/allergies. These are areas where many natural therapists excel.
And don’t start me on the doctor who is looking at a computer screen…..
I’m not sure this accusation can just be made of (most it seems) doctors these days. I think it’s the over reliance of technology in many areas. For example, the good old fashioned mechanic who could diagnose a fault just by listening to a car’s engine, has now been replaced by a technician who runs a diagnostic check. But if the diagnostic check comes back clean, the technician’s stuck. I know, it’s happened to me. A time served mechanic diagnosed a fault within seconds as being dangerous (just by listening to the engine using a “stethoscope”), even though the technician had earlier passed the car as being roadworthy because the computer said so.
I know of someone in their late 20s who had complained of general aches and pains for a few years, progressively getting worse. All the tests were negative. Latterly he lost the partial use of one of his arms. All the tests and scans came back clean, ie there was nothing wrong with him. His funeral was last week.
I’m sure there’ll have been an autopsy.
Spot on, John. The reference range for and diagnosis of hypothyroidism is a case in point. Hypothyroidism is defined by numbers. Where do the numbers come from? According to wikipedia, “a reference range is usually defined as the set of values 95 percent of the normal population falls within.” If this is the standard used for diagnosing hypothyroidism then it follows, a priori, that 5% and only 5% of the population is hypothyroid. In other words, the disease is defined by statistics, not symptoms.
It’s not just doctors that overly rely on technology. How about the pilots of Asiana Flight 214 that crashed recently at San Francisco Airport? They relied on automatic systems that they didn’t fully understand. Shut the systems off, grab the stick and fly the big bird!
Recently my very thin,19 year old grand-daughter was in the hospital complaining of upper abdominal pain, she was scoped, x-rayed, blood was drawn etc. Everything was “normal” yet the poor girl was suffering. Finally a hospitalist had her gall bladder tested. The nurses and interns were openly skeptical. The results? Her gallbladder was not functioning at all. I asked the Dr why he tested her for that when everybody else said there was no way her gallbladder was a problem, his reply “A patient will tell you what is wrong, if you will just listen” I wish more Drs would follow that advise.
Totally agree. I have been on the receiving end of a battery of (negative) tests which went on for about 18 months. Finally after a lengthy consultation with an NHS consultant, who did not, also, try to steer the consultation in a particular direction, I was given a provisional diagnosis (then confirmed by MRI scan). Strangely, I have never been so relieved to be told I actually had something wrong with me.
Maybe it’s not the testing but the tests? Having read Dr. Jack Kruse’s book and spent time on his website it would seem rather than testing for a diagnosis the testing should be for causes. His theory is that all Neolithic illness stems from inflammation and the cause of inflammation can be determined by blood tests. His tests though look for heavy metals, mould, thyroid function but not the standard tests mostly ordered. The tests are ordered by looking at the symptoms and genetic make up. That seems to me to be a far more sensible approach. I can’t see though that if I turn up at the GP and start telling them what tests I think I should have that I would get very far. What’s needed in modern GP practice is a dose of enlightenment and the desire to go forth into google and re-educate themselves. I swear some of them are still heating up jam jars and making potato poultices and recommending stitching yourself into a liberty bodice for the winter!
We can apply evolutionary theory to the proliferation of tests. Their emergence equates to mutation of method(s) where diagnostics are concerned. Rank empiricism is replacing skilful detective diagnostics. Why?
The labs have proliferated in time, and so has their hardware, and in the last five decades a lipid profile test has become a no-brainer, “so while were about that and while we have needle in the patients arm lets pot up some samples for .. .. and . ..”
The testing labs represent industry and any industry is out to expand its markets and testing labs have done the same. The marketing of tests follows the came principles as anything else, emphasise the claims and don’t mention the pit-falls. I’d expect the perception of the benefits of many a test has many medics thinking its efficacy and reliability is greater than the reality.This is certainly the case with the lipid profile test, the so-called test for cholesterol that doesn’t test for cholesterol and doesn’t acknowledge the fact that cholestane triol is atherogenic whilst pure cholesterol is not. We, ‘they’, never question the efficacy of the technology.
I recently had a Drivers Hours Infringement Report generated by Tachomaster software. Once folks see that report on paper nobody wishes to hear protestations and nobody conceives that the software may not handle the analysis of a particular case very well. “it’s a lack or foresight written into the algorithm, stupid! The writers of the algorithm and computer software had insufficient real-world experience to plan for all cases, leaving a significant hole in the software’s ability.”
All around us we are great at harnessing human intelligence to fashion and implement technology, but were just not smart enough to use these tools intelligently. Increasingly we fail to wonder if the tool is a weak one. Sometimes it’s the tool that deserves the blame.
I agree with almost every comment here. One doctor I see, an elderly thyroid specialist in private practice, relies on the ‘Mark One eyeball and the Mark One ear hole’ to adjust my treatment, with far more success than my 20+ years of the standard NHS TSH blood test. I can now gauge the adjustment for myself, if need be. From my long experience as a patient with many chronic problems, this man is rarity.
Just one more example from my store. I’ve had Pernicious Anaemia (auto-immune) for many years, but the NHS will only allow a one-size-fits-all injection of 1mg hydroxocobalamin quarterly. As long as the all-important blood test records your B12 serum levels somewhere in the statistically derived reference range, one is absolutely fine, according to current practice – even if if one continues to suffer the effects of B12 shortage. I have struggled to get even this much treament from my local GPs, so I had to approach another doctor I know for fortnightly treatment to help keep the PA problems at bay. These are significant, encompassing my balance and other types of neuropathy, including chronic pruritis. I would have the treatment weekly if it were possible. NHS doctors have accused me of faking these symptoms or having a mental health problem, because their batteries of tests did not reveal anything.
Helen,
What pray tell is the ‘Mark One eyeball and the Mark One ear hole’ method. I can’t find any reference to it online.
I remember a few years ago an article in the Los Angeles Times’ “health section” by a doctor charged with training up and coming interns and residents bemoaning the fact that the newest crop of doctors had never been taught the art of the stethoscope, but rather were relying on electronic and machine testing protocols. This doctor insisted that all those under his charge must learn to use a stethoscope for hearing heart and lung sounds. For myself, I don’t like it when my blood pressure is taken by an electronic machine. The few times I’ve asked for a manual blood pressure reading, the nurses rolled their eyes at me. One told me she didn’t even know where a blood pressure cuff might be on the unit. That’s comforting! A doctor treating solely by numbers on a test result is nowhere close to practicing the art of medicine. One size does not fit all in the numbers.
Not so sure about this article.
If you have the technology available then we should use it.
What about the Dr that doesnt refer for a test for a patient who ends up having a chronic illness, and then the patient sues his sorry arse???
If your tests come back clean, why should this be the Drs fault for being cautious??
The first person the patient will blame if something is undiagnosed is the Dr.
Spot on! And by complete coincidence, only finding this Des Spence piece from one of blog followers, I wrote this today http://heroesnotzombies.com/2013/12/19/data-algorithm-drug-is-this-the-way-to-practice-medicine/
#Bob Your article (above) summed up pretty much what many people in this thread seem to experience and believe about General Practice. It is a huge relief to hear compassion and common sense applied to medical expertise. I imagine lots of contributors wish you were their GP. Please keep up your efforts to make medicine a ‘father and a mother’ and not just a ‘hard drive’.
to Ryan – there’s always an appropriate time and place for using tests, to confirm, not as a starting point. When testing is the default rather than a doctor using his observational skills and experience, there’s a big problem in the practice of medicine. Of course, a doctor doesn’t get the chance nowadays to get to know the patient. Sometimes tests are all a doctor has to go by. Very sad.
I went for about 10 years with my primary hyperparathyroidism being undiagnosed. My first symptoms were fatigue. Several GPs had no explanation and very vague recommendations. After a couple of years an alternative biochemist / naturopath said I should have a bone mineral density test based upon his hair analysis. My doctor laughed at first, but I insisted, and a scan revealed quite well advanced osteoporosis. Still no doctor suggested a parathyroid test. Six years of standard osteoporosis treatment had not effect. And my other symptoms of fatigue and mental fogginess continued. Finally, finally, finally my GP despaired and sent me to a specialist, who included a PTH test which showed primary hyperparathyroidism. Appropriate surgery has resulted in steady reversal of symptoms. Looking back at the descriptions of how hyper PTH presents, I had many of the signs and symptoms – surely they should have been diagnosed much earlier with proper history taking. Only the “alternative” practitioner got half the diagnosis right in those first few years.
I can but totally agree with the article and the subsequent comments. I have managed with great luck to avoid the need to consult with my GP for a number of years, but I have been fascinated watching vets dealing with our dogs. Our current vet is a ‘hands on’ diagnostician first and foremost, only ordering tests as a confirmation. It is truly wonderful to watch him going over every inch of the animal, asking pertinent questions of us and then making a diagnosis. Sometimes he doesn’t have a diagnosis, but has the intellectual honesty to admit that fact! Previous vets hardly touched the animals, and would order tests and/or send the animal on to a specialist instead of diagnosing. I have the feeling that often our GPs , like many vets, are no longer acting on their own behalf, but act as intermediaries to consultants.