|Distorted Reflection by Anthony Papagiannis|
On the desktop, printed in fancy lettering on expensive paper, lies an invitation for the opening of yet another big diagnostic center. According to the brochure, it will provide the latest equipment in ultramodern premises, perform all sorts of investigations with faster results than ever, and have the plushest armchairs for the patients, even treating them to free coffee while they wait. The solution to any diagnostic problem is just a request form away.
Or is it?
Years ago I faced a strange problem with my car: without any warning the engine would go dead in most awkward and even dangerous circumstances (e.g. in heavy traffic or while overtaking a slow lorry on a mountain road). After a few seconds it would fire normally again, but the mysterious arrest would recur unpredictably. I took the car to the service people and recounted my problem. “The computer will tell,” they said. They hooked up an expensive piece of equipment to the car’s “brain”, took their readings, and told me that everything was fine. Reassured, I drove off only to have the same thing happen soon again. “The car brain must be faulty,” was the next diagnosis, and they ordered a new one for transplantation. Meanwhile the problem persisted, so I asked to see the chief engineer and explained everything in detail. “I’d like to drive the car myself,” he said. After ten minutes of test driving and having personally experienced the problem, he asked his assistants to empty and clean the fuel tank: a small piece of dirt floating in the gasoline would block the fuel intake at random intervals, causing an abrupt standstill of the engine. As soon as the engine stopped, the speck would float away and engine life would be restored. The car and I were spared the unnecessary “brain” transplant (which would have been totally ineffective) and the associated cost.
One can extrapolate the lesson from my car trouble to the modern diagnostic process. In a word, costly technology is not synonymous with good medicine, and state-of-the-art shiny and expensive equipment cannot replace an astute and meticulous clinician. Without a detailed history, careful examination, working hypothesis, and targeted investigation of the likely problem, multiple and sophisticated tests may cloud diagnostic thinking or even send it on a false trail. The best car computer in the world could not have picked up the speck of dirt in the fuel tank. The latest computed, magnetic resonance, positron emission, or other space-age scanner cannot diagnose, for example, mental stress as the root of a headache or a viral infection as the cause of a patient’s cough.
Even academic medicine may fall prey to technological extravagance. Many years ago in Britain I had attended a grand round about a young woman, an exchange student in the United States. She visited a doctor there with unexplained shortness of breath and underwent numerous studies at a university hospital. The conclusion was that she had end-stage respiratory failure and her only option was a heart-lung transplantation. In desperation she returned home to Britain and consulted a local specialist, who after a meticulous clinical assessment diagnosed vocal cord dysfunction related to stress and recommended appropriate counseling and speech therapy, with good results. An American professor visiting at that time estimated the cost of the investigations at a cool fifty thousand dollars (in 1991). To what effect?
Medical technology has taken us to places in the human body where no man had ever gone before, at least not without bloody and risky surgery. It has brought to light details of physiological and pathological processes hitherto invisible and beyond imagination. But gradually and unfortunately, at least in the civilized world, market forces have got the upper hand in its utilization, and work largely uncontrolled. This leads to a forest of results, numbers, figures, graphs, and images that often hide rather than reveal the single tree one is looking for, as well as causing a disproportionate expansion of the cost of healthcare. I used to wonder at the number of CT scan reports ending with a recommendation for “further evaluation by MRI” until I realized that the same diagnostic center provided both imaging modalities.
Worse still, patients sometimes embark on diagnostic tests on their own, starting with what they believe is the source of their health complaint. Then occasional obscure phrases in the reports or asterisks denoting “abnormal” (i.e. statistical outlier) values for some results create waves of anxiety and panic. These patients then start making the rounds of specialists for an interpretation of these abnormalities.
Even at this stage there is room for damage limitation. The wise physician will put the test reports aside and focus on the sick person before attempting to interpret the results. Only in the context of the patient’s history and physical findings can test results illuminate rather than obscure and distort the diagnosis. This is why investigations should only be done at the request of a responsible clinician who gets the results, interprets them in the light of the already elicited history and physical findings, and then translates them in a layman’s language, thus sparing the patient much anguish and futile quest.
The thirteenth century theologian Thomas Aquinas described philosophy as the handmaiden of theology (philosophia ancilla theologiae). In a similar vein, technology should be the handmaiden (and not the mistress) of medicine: if the handmaiden is good at her job and does what is required of her, all works well in the house. If the roles are reversed, something is bound to go wrong. If a patient’s anxiety and panic infect an ill-informed and unwise doctor, the next stage of the patient’s itinerary may be inappropriate surgery. As Yogi Berra put it, “If you don’t know where you’re going, you may end up elsewhere.” This dictum may have dramatic effects in clinical medicine.
ANTHONY PAPAGIANNIS, MD, MRCP (UK), DipPallMed, FCCP, is a practicing pulmonologist in Thessaloniki, Greece. He received his MD degree from the Aristotle University of Thessaloniki Medical School and trained in Internal Medicine in Greece and subsequently in the United Kingdom, specializing in Pulmonary Medicine. He holds a postgraduate diploma in Palliative Medicine from the University of Cardiff in Wales, United Kingdom. He is a postgraduate instructor in palliative medicine in the University of Thessaly in Larissa, Greece and edits the journal of the Thessaloniki Medical Association.