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Much of the time medical professionals are working in the heavy
gloom, if not in the dark. So, what do we do:
- Ask the patient what is wrong
- Examine them
- Do tests
- Reach a diagnosis
- Give treatment
- Follow up
Easy? Well it is an ordinary degree, not an honours.. But
if you want more detail:
Ask the patient what is wrong
A number of patients at this point reply: 'It's your job to tell
me', which, in a way, is fair enough. Vets do it all the time.
However the story the patient tells you is the most important part
of the whole rigmarole. Good doctors try not to interrupt, no matter
how incredibly irritating the patient may be, but this can be hard,
especially when time is short, which it always is, especially at
four in the morning. The history of the family, including the family
pets, can be quite toe curling. My boss used to say
that it was important to stay 'just on the gentlemanly side of aggression', when
taking a history. This is considered very non-PC these days. Most
young doctors are females these days, so substitute 'lady-like'.
There are a number of problems. Patients are usually terrified
that doctors will either tell them they have something seriously
wrong, or will perform degrading acts on them, with the impunity
that a medical degree allows. This makes them less coherent than
they would be in, say, the pub. They will probably be of a different
social background to the doctor and have a variety of names for
parts of their anatomy not normally found in a genteel middle-class
family. Patients and doctors have different ways of describing the
same thing and often patients find the medical term rather rude.
Different parts of the country have different
traditions too, to say nothing of different countries. My first
encounter with a Glaswegian led me to believe that he was speaking a
different language, apart from the swear words. The phrase 'I feel sick doctor' can mean a wide variety
of things, with a wide variety of importance, sometimes of immediate
significance for the doctors' suit or dress. Having got the
main story, doctors ask about other things that are important, but
the patient has not mentioned. There is a sort of general agreement
about what should be asked, but no International Standard List,
though doctors who use some sort of list are shown to be better at diagnosing complaints.
Patients get quite confused by this: asking about headaches or
periods, when a
bruised foot is the problem can seem silly and suggest the doctor is
either thick, missing the point or taking the piss.
Examine them
 This
is the Sherlock Holmes bit. Generally a small callous on the inner
middle finger of the right hand does not automatically tell most
doctors that the patient is a seamstress from Bolton who has had to
do with seafaring folk as it might Sherlock Holmes, whose skills, as
I am sure you will know, were based on a Professor of Anatomy at
Edinburgh. In general practice the fact that a patient can walk in
and sit on the right chair can tell one quite a bit. My boss, yes
that one, once informed me that a patient wearing suede shoes with
an anal problem was most certainly gay (he didn't call it
gay).
Again there is not really an International Standard List of signs
to elicit (jargon for finding lumps, bumps, squeaks or rattles and
the various sounds the heart can make when bits of it fur up). This,
again is a pity, for where such a systematic list is used doctors
tend to do better. Some examinations, usually involving putting
things into orifices that appear definitely too small for them, can
be sore or embarrassing.
Tests
These can be blood tests, which can be quite nasty if the doctor
nurse or phlebotomist (posh name for blood letter) is not much cop at their job. Lots and lots of
other tests involving various forms of scanning devices may be
pretty pain-free, except you may have to lie in a rather tight tin
can while loud machinery assails you. Others may require an anaesthetic. Doctors
generally do too many tests. This is expensive and may be misleading.
Junior doctors generally order tests and tend to be scared if they
miss any as their boss may be cross with them, so that they may find
that their next job is a genito-urinary clinic in Wigan. This
appeals to a relatively small proportion of doctors, I understand
Diagnosis
The point of the aforementioned is to lead one to a diagnosis.
Curiously diagnoses, despite being important are often vague and
woolly. They are given long names, often a mixture of Latin
and Greek, a throwback to the time when doctors would discuss the
patient between themselves, across the bedside, in Latin in order to keep the patient in the
dark. 'Idiopathic' sounds much better than 'search me'. But even a common
diagnosis like asthma, has a wide range of signs and symptoms,
generally clustered around wheezing, but not easy to pin down in
every case. Syndrome means 'the group of symptoms this patient just
told me they had', which I have come across before, but don't really
know what it is, so doesn't really lead one much further.
Treatment
Once a diagnosis has been reached the treatment should be fairly
simple to apply, maybe. But, humans are never that simple. Firstly
virtually no treatment is completely effective. One way to describe
this is to talk about the
number needed to treat, (NNT) which means the number of people
 who need to be given the treatment for one to get benefit. It is a
surprise to many people that an NNT of, say five, is really pretty
good, despite the fact that it means that one needs to treat five people before one receives any benefit.
This link shows some NNTs for painkillers. None are 100%, which
would be an NNT of 1. Tramadol, for instance, is between 4 and 6 for different
studies, which suggests that at least 3 out of 4 people get no
benefit.
On top of that the best treatment may not be possible for some
people. Penicillin may be the best treatment for a problem, but the
particular patient may be allergic to it. Or they may be taking
another treatment which makes the desired one dangerous or
ineffective.
Follow up
Generally doctors are not good at following up their patients.
Don Herold said that 'doctors think a lot of patients are
cured, who have simply quit in disgust'. Doctors are just pleased
that a patient has not come back, and being generally optimistic
folk, assume that he or she is better.
A short history of medicine:
2000 B.C. - "Here, eat this root."
1000 B.C. - "That root is heathen, say this prayer."
1850 A.D. - "That prayer is superstition, drink this potion."
1940 A.D. - "That potion is snake oil, swallow this pill."
1985 A.D. - "That pill is ineffective, take this antibiotic."
2000 A.D. - "That antibiotic is artificial. Here, eat this root."
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