To become a great diagnostician, you need to excel in five different areas: (1) history-taking, (2) physical examination, (3) laboratory medicine, (4) radiology, and (5) electrocardiography.
The two most important components of history-taking are knowing what to ask and how to ask questions.
Prepare and perfect scripted questions for common diseases and presentations. For example, heart failure and volume overload are commonly probed with questions about leg swelling, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. There are, however, many more questions that could be asked to help tease out symptoms of heart failure. These might include questions about diuretic or dietary noncompliance, weight gain, increased abdominal girth, missed hemodialysis, cough, wheezing ,etc. Learn all the scripted questions that are relevant to diseases that you see a lot of. (I am not aware of many excellent books on clinical history taking. A reasonable place to start might be The Patient History: Evidence-Based Approach (2012) by Mark Henderson. Others might prefer Symptom to Diagnosis: An Evidence Based Guide, Second Edition, by Scott Stern.)
How to phrase your questions can be extremely important, especially when dealing with sensitive topics. “Always the beautiful answer who asks a more beautiful question,” is a quote that is attributed to e.e. cummings. “Do you hear voices?” or “Do you want to kill yourself” are rather inelegant and low yield questions. Test drive and flesh out phrases that make patients feel less uncomfortable, such as “Does your mind ever play tricks on you?” or “Did you ever feel as though life is not worth living?” You can always follow up later with more specific and direct questions. (See, The Psychiatric Interview (2011) by Daniel Carlat for lots of ideas on how to ask questions.)
By far, the best way to learn how to do a physical examination is to do it many times under the tutelage of a seasoned teacher. Nothing even comes close to this method of learning, especially, and somewhat ironically, when it comes to the musculoskeletal examination. Certain maneuvers cause “clicks” and sensations of “give” that one cannot even partially experienced by reading books or watching videos. Rather, you need to examine lots of “normals” and lots of “abnormals,” under competent, and preferably excellent, supervision and guidance. So try to stick around and watch as your consultants as they examine your mutual patients. Ask them what they are doing and ask them if they might be willing to watch you try whatever provocative test they are doing.
Most clinicians can read and interpret a white blood cell count with differential or a basic chemistry panel without any difficulty. So focus instead on other common, high yield, and often extremely nuanced laboratory studies, such as liver chemistries, urinalysis, peripheral blood smears and acid-base pathophysiology.
If you excel at reading chest radiographs and head CTs, can identify the most critical, deadly and dangerous radiology findings, and you otherwise choose the correct imaging studies, you can probably consider yourself excellent, or at least close to excellent, in this area.
If you can’t read a foot MRI, you can almost always wait for a competent radiologist to help you out. There is, however, no substitute for being able to interpret chest radiographs and head CTs on your own and in a timely manner. “Perhaps the most important clinical advice to the front line doctor with regards to emergency brain CT scans for trauma or any other reason is for you to look at the scan [and interpret it!] as soon as it is done.” Brain CT Scans in Clinical Practice by Usiakimi Igbaseimokumo MD (2009, p. 33)
So strive to be as best as you can be in these areas. Again, there are tons of good radiology books out there. So get started!
“If you think there’s another specialist who has all the answers, someone else who’s going to bail you out of trouble every time you have a question about ECGs, you are mistaken. That person may just as likely be wrong, so YOU must strive to become THE expert.”
Amal Mattu MD, ECG Interpretation of STEMI: Who’s the Expert?, Medscape. Mar 21, 2012.
I’ll add to that the rather obvious point that your patients will invariably live or die because of your EKG interpretations, try to excel in this area.
There are many good to excellent electrocardiography books and blogs out there, so get started and don’t every stop learning.
Your time is finite, so focus more on diagnoses that are more common and that matter most in terms of patient outcome. Knowing how to distinguish pericarditis from STEMI, for example, matters a great deal. There is no substitute for you knowing how to make that distinction accurately and in a timely matter.
Also, focus as much as you can on toxicology and especially on iatrogenic conditions. Often the best way to clarify what’s going on with the patient is to stop some or all of the multitudinous medications that the patient is taking – and see what happens.
Please let me know if you have any other ideas on how to become a great diagnostician.
by Mark Yoffe MD
[Please read important Disclaimer.]
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