diagnostic skills

Diagnostic skills

A friend who is a primary care doctor once told me that 85% of the

symptoms that he sees in patients don't matter. They will simply go

away over time. Jerry Groopman notes the same in his book How Doctors

Think (on page 100): "Nearly all of the complaints patients describe

to their primary care physician, such as headache, indigestion, and

muscle pain, are of no serious consequence."

This makes it all the more impressive when a PCP has the diagnostic

skill to notice the symptoms that do matter. This is especially the

case for pediatricians, who often have to rely on noncommunicative

patients and parents' descriptions of their child's symptoms. Two

stories of this ilk follow.

A baby and mom go to visit the pediatrician for a "well child visit"

several weeks after the child's birth. Everything seems normal, and

the visit is about to end. The doctor closes with one last question:

"Is there anything you have noticed about Sally that has you curious

or concerned?" Mom replies, "Well, I notice that she sweats a lot

while nursing." Alarms go off for the doctor, who suspects a problem

and orders tests. It is found that the child has a rare heart defect

that prevents proper blood flow, particularly during the somewhat

strenuous nursing activity. Cardiac surgery is undertaken, and the

baby is fine, avoiding major complications that might not have showed

up till years later.

Another child, a two year old girl, returns to the PCP with the second

urinary tract infection ("UTI") in as many months. Alarms go off for

the doctor. After assuring herself that the parents are using proper

sanitary practices during diaper changes, she orders a test of urinary

function that indicates reflux of urine from the bladder back to the

kidneys. The little girl's ureters are not properly implanted in the

bladder, permitting backflow. The pediatrician notes, "I've seen too

many teenage girls with kidneys damaged from years of undetected

reflux and persistent UTIs." After several months of prophylactic

antibiotics to see if the girl will outgrow the problem, she undergoes