The People's Perspective on Medicine

Show 881: The Art of Diagnosis (Archive)

The ability to make a diagnosis based primarily on physical examination and talking with the patient has been withering; what are we losing?
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The Art of Diagnosis (Archive)

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Diagnosis is the very foundation of medical care. Without an accurate diagnosis, doctors have no way of determining the appropriate treatment.

Decades ago, doctors used to rely heavily on the patient’s account of her problem (called the “history”) and the doctor’s direct physical examination of the patient. Medical students still learn these skills, but in practice many physicians order images without conducting a thorough physical exam. What factors are behind this trend? What are the consequences? We talk with Dr. Abraham Verghese about the art of diagnosis and how the process can sometimes go awry.

The Physical Exam:

The ritual of the physical exam also establishes the human connection between doctor and patient as one focused on healing, even when a cure is not possible. Has medicine become too focused on quantitative measures and standardization? Find out how over-reliance on high technology might be reversed and whether the culture of bedside medicine can be revived.

This Week’s Guest:

Abraham Verghese, MD, MACP, Senior Associate Chair and Professor for the Theory and Practice of Medicine at Stanford University School of Medicine. His books include My Own Country: A Doctor’s Story, The Tennis Partner and a novel, Cutting for Stone. Dr. Verghese is online

Learn more about the Stanford University Medical School program he leads at
The photo of Dr. Verghese is by Sean Nolan.

Listen to the Podcast:

The podcast of this program will be available the Monday after the broadcast date. The show can be streamed online from this site and podcasts can be downloaded for free for four weeks after the date of broadcast. After that time has passed, digital downloads are available for $2.99. CDs may be purchased at any time after broadcast for $9.99.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
Show 881: The Art of Diagnosis
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Learn how the physical exam helps the doctor and patient focus on diagnosis and healing, even when a cure is not possible.

Show 881: The Art of Diagnosis
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Wish you made it easier to find the digital download for this program.

The digital download of this program will be available for free (for four weeks) on the Monday following the radio re-broadcast date (In this case, Monday July 6th, 2015). Look for it in iTunes, and we’ll also have a link to it on this page, as well as the option to listen to it streaming from this page as well. Thank you for your interest!

I agree. I actually a “complete” physical. Dr. just cked my heart and lungs. Another doctor at a major US hospital didnt believe my history. I left the office!

After increasing ear pain, I was sure I was getting an ear infection. At my Dr.’s office I was seen by his Dr.’s assistant and prescribed antibiotics for an infection.
I asked then to see my doctor, who looked in and felt my ear and jaw area. He said, “Don’t worry, take some ibuprofen, it’s just residual joint pain from the Chicangunya you had last fall.”
Much relieved, I went home and used a warm compress and messaged the jaw joint. The pain disapated over the next few days. It is good to have a doctor who knows me and my history!

Agree… Physicians need to listen to their patients. A perfect example is my son, he is 15 and had a fever of 104. Was taken to an urgent care and had 2 (yes two) Rapid Strep tests done. He was then referred to an Emergency Room because the practitioner could not make a clear diagnosis (apparently it was NOT strep throat). A 3rd Rapid Strep test was performed at the ER and was again Negative. Nobody even cared what the first two tests results were and had it been a CT scan he may have had three of those in one day. Shameful. Obtaining a thorough history can lead (in my opinion) to a diagnosis 80 to 90% of the time. When I ask the right questions and listen to my patients, I can make a diagnosis without ever ordering a test.

Despite the fact that 3 Rapid Strep tests were negative, the physician at the Emergency Room still wrote a prescription for an antibiotic (unnecessary). Turns out when I saw a grainy cell phone camera picture of my son’s throat and mouth and then asked him if he had lesions on his hands (yes, small red lesions) I was able to make the correct diagnosis 200 miles away … it was Hand-Foot-Mouth disease, a self limiting illness that requires no antibiotics.

Had they asked the correct questions and listened and obtained a proper history, very likely unnecessary tests would not have been ordered and a correct diagnosis would have been made.

This is a very important issue and one key underlying reason for the increasing cost of healthcare in the US. I am a radiologist and see a constant stream of scans performed on patients that clearly did not have a thorough history or physical exam. This becomes evident to me based on the history I am given and the findings on the test ie. CT of the abdomen and pelvis for abdominal pain shows constipation – this diagnosis should not require a CT scan.
Recently my father who is also a physician went to the hospital after passing out vs. being knocked out while playing soccer. He would have had to leave against medical advice in order to prevent some of the unneccessary tests he was subjected to. He did refuse some of the most dangerous tests that were proposed (coronary angiogram – he never had any chest pain or other cardiac symptoms and had no risk factors). But, other tests were insisted on by the various subspecialists he saw before they would agree to let him leave.
The tests were performed with no regard to his history and physical exam and the results were contradictory and indeterminant in some cases (as would be expected when the pretest probability is low).
When he was discharged, he was given scripts for medications that are not appropriate or indicated for him, again based on the contradictory and erroneous results of the inappropriate tests and disregard for the clinical history. Needless to say he is not taking those medications.
I cringe to think what would have happened if he, I and my sister were not all physicians and could not judge for ourselves that the tests and medications were inappropriate. If the history and physical exam were thorough and if the physicians he saw were able to use their clinical judgement, he would have been sent home the day he came in (rather than 3 days later) with a much smaller bill, less radiation exposure and only one prescription instead of 3.

I totally agree that most physicians have lost that caring touch, My husband goes to a health clinic that has a sign in the room , ONE SYMPTOM-ONE VISIT, . He is a diabetic, with many issues but only one per visit. And when he is there, the care provider sits in front of the computer and enters in data and then maybe will come over and check his heart with a stethescope and that’s it. Has never looked at his feet or legs, he has never been undressed, MEDICINE IS A FARCE

I totally agree that most physicians have lost that caring touch, My husband goes to a health clinic that has a sign in the room , ONE SYMPTOM_-ONE VISIT, . He is a diabetic , with many issues but only one per visit. And when he is there, the care provider sits in front of the computer and enters in data and then maybe will come over and check his heart with a stethescope and thats it.Has never looked at his feet or legs, He has never been undressed, MEDICINE IS A FARCE

Where I trained, we were taught that labs were meant to confirm a diagnosis, and that we should have the diagnosis and problem list 90 percent of the time based solely on the H&P.
I also recall my first lesson in the physical exam as a 1st year student. I asked the clinician before we saw my first patient whether he ever felt overwhelmed by the vast number of diseases we have to know. He replied “But you have the patient right there in front of you.” It didn’t mean anything, of course, until I learned the diseases. Not taking anything away from the life-saving role of specialists, but it cemented in me the value of the basic physical exam. Great program!

My stepfather was an old-time diagnostician. He spent 1/2 day interviewing his patients.He often would notice a blemish,a mole,a cough, or breathing issues in situations other than doctor-patient.
We had a lot of confidence in his ability to figure out problems; over his lifetime of 97 years he explored many different medical practices. He was pretty radical, but we would always try some of his latest theories!

This was one of your all-time best shows! I felt as though my dad, a beloved country doctor in Western Maryland, was talking to me through Dr. Verghese. If I were young enough to go into medicine, I would be heading to Stanford.

High Touch trumps High Tech, 80% of the story will be revealed through careful history and physical and saves $$ in the long run. Culturally competent and caring physicians are essential to improve outcomes in the clinical care setting. People’s Pharmacy programs are an inspiration to me and my students in a time where efficiencies and bottom lines are held out as priorities over true quality and patient satisfaction from strong patient physician relationships.

hi,I have a doctor that orders tests, but does not follow through on them. last year I had a chest CT, and it stated that I had lobarpneumonia, and it should be followed up further. My doctor went on vacation, I became severely worse, and ended up in the hospital with double lobarpneumonia & congestive heart failure. All I can say is it was horrible what I went through. Then I fell and fractured l 2/3 in march-2012. I was supposed to have cyphoplasty surgery. Needless to say, his gal that does the referrals placed my referral on the bottom. I called many times, and the doctor did not get the referral until July. He wanted another MRI.
I was in a great deal of pain,and in the time that had passed l 2/3 had collapsed, and the upper thoracic bent to the right. The doctor could not help me. I have learned that when I have a test, I shall do my own follow up, and find my own doctor. I know that the doctors are very busy, but they should not order tests, and then do nothing to help you in the follow ups. We depend on their knowledge. God bless, Fonnie

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