Blog | Thursday, September 21, 2017

Are we developing the next generation of diagnosticians?


A senior consultant lamented to a colleague that he worried about the future of diagnosticians. Diagnostician once described the epitome of internal medicine. You could not give an internist a greater compliment. But this consultant felt (whether he was right or wrong is unclear) that too often our younger colleagues lack diagnostic curiosity.

This question is legitimate, but very difficult to answer. When I give my favorite Grand Rounds talk, “Learning how to think like a clinician,” I try to emphasize the importance of accurate diagnosis. Every day on rounds I am skeptical about diagnoses. I treat all diagnoses as unproven, unless I can see definitive proof. I question the emergency department, the intensive care team, the primary care physician, the subspecialists and even myself.

Apparently this skepticism is a bit unusual. I know that I have made diagnoses because of this skepticism.

Diagnosis requires patience and significant detective work. Most diagnosticians admire Sherlock Holmes because he always questioned assumptions and answers made based on incomplete data.

I hope that some of our younger colleagues are accepting this mantle. We need internists who focus on diagnosis. We need internists who do not automatically accept admission diagnoses, but rather interpret that diagnosis as a suggestion. Of course, I remember all the diagnostic errors that others have made.

The current focus on algorithms, checklists and guidelines only works after correctly diagnosing the patient. Diagnostic errors remains rampant. Diagnosticians unfortunately often are swimming upstream. But our subspecialty colleague respects the “old school” internist who pushes to understand.

I am proud to be considered a diagnostician. We get no points from insurance companies or quality metrics. We merely help patients through our insistence on diagnostic thoroughness. And patients greatly appreciate our efforts.

This is our calling, our mission and our passion. We need diagnosticians. If you can, please make it your goal above all others.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.