Get the Diagnosis right

When I was learning to be a doctor a very wise senior GP sat me down and told me that the secret of being a great diagnostician was to be a good listener. That surprised me. Not learning lots of clever examination techniques or learning to interpret fancy tests? No, You need to be able to do that of course but the most important thing is to listen to the story, because all the clues are there. Don’t be tempted to leave out the bits that don’t fit your working diagnosis , they are there for a reason. Work out why they are there and you will find the answer. Don’t interrupt the story teller, within a few seconds of them starting, give them time and you will hear all you need. And it works. As a GP sometimes I have literally bitten my tongue but I always tried to listen. This week a young man presented with intermittent abdominal pain and fever. He had symptoms for over 6 weeks. The GPs he saw ( and he saw 5) tried to tell him he had diarrhoea , but he said gently and with clarity, no not really… no one really listened to him or why he was there… some minor infection? IBS? Nothing to worry about, but he was worried. He was a fit young man, didn’t like doctors and rarely went to see them, had had several significant sports injuries and continued to play football despite pain. Something felt wrong. HE was given a myriad of medications. None worked and on reporting the ineffectiveness he was told to keep taking them and new ones were added. Then finally a documented fever of 40.4( no one picked up on the clear history of a fever because when he was seen before he didn’t have one). Well that isn’t normal and rebound so suddenly hospital and ? Appendicitis which turned out in fact to be a serious but rare infection which caused his abdominal nodes to be full of pus…he is okay now- home and full of the right antibiotics. Finally it was the senior surgeon who listened to the story without interruption or need to make it simple, who enjoyed the challenge of something out of the ordinary and found the problem he needed to solve.

And I wondered why did it take so long? Yes it was rare but the clues were there all along…we make dangerous assumptions based on prejudice. We excuse ourselves because we are busy but failing to listen in the end takes longer….

And I wonder do we listen to patients, to the public? To other clinicians? Do we listen to the evidence? In the complex world of health care do we seek the simple diagnosis, the simple fix and ignore the complexity because it doesn’t fit into a sound bite? Because when you identify how complicated and multifaceted a problem is it feels too big and scary to tackle whilst reducing it to something smaller and neater feels safer. But failing to diagnose the problems accurately is dangerous. Quick fixes may make us feel better because we have done something but ultimately don’t sort out the problem. The young man I mentioned was given antibiotics by the out of hours service doctor he saw for no particular reason and without a diagnosis. That was the wrong thing to do and it complicated the picture. Some problems take time to understand and then to fix a bit at a time. When we as a CCG are trying to do things differently do we listen well enough so we can actually define the precise issue we are trying to solve… do we as a system listen or do we just blindly stumble forward…It is a gift to be able to think freely…to look at an issue without the weight of a forgone conclusion…With so much pressure on the system now to make everything different really fast do we have the collective courage to do the right rather than the expedient thing? Don Berwick’s diagnosis was thoughtful, complex, clear. He has listened. It is really worth watching it. http://www.kingsfund.org.uk/audio-video/don-berwick-improving-safety-patients-england-full-presentation. Some have criticised it for being too woolly without enough concrete recommendations, but that is absolutely the point. It isn’t about implementing a new structure or a new set of rules. So much of what is wrong with the NHS is about a culture of blame, fear, and lack of transparency. We need to understand that and change it to pride, joy and openness. Doing that will take time and individual commitment from all those who lead the NHS. You don’t change how people feel and act overnight. More importantly will the system we work within give us the permissions we need to fix the problems fundamentally this time, or are we just in another cycle of short courses of ineffective medicines…