- Email: [email protected]
DIAGNOSIS: THE CLINICIAN AND THE COMPUTER
984 so
Letters to the Editor
urgently required. Students and newly qualified doctors acquainted with the following facts:
must be
(1) General practice
can
be
a
stimulating
and
satisfying specialty.
DIAGNOSIS: THE CLINICIAN AND THE (2) Good medicine can be, and is, practised outside the hospital walls. COMPUTER (3) All the " interesting cases " of hospital medicine come from SIR,-I think Professor Scadding’s article (Oct. 21, p. 877) general practice in the first place. illustrates well the struggle of the modern clinician to free (4) There is room for the superior intellect in general practice himself from the constraints of the concept of rigid disease because: entities. Yet without classification, there would be chaos. (a) Cases came to notice much earlier, with fewer physical signs than the consultant sees, and therefore the diagnostic challenge It often seems unreal to squeeze the data appertaining to a is greater. into an But it is necespatient existing diagnostic category. The problems are of infinite variety, and many skills other (b) sary to make at least a provisional diagnosis in order to draw than purely medical ones are called for. on past experience as a basis for prognosis and treatment. (c) With the infrastructure of registrars, housemen, and students I believe computers can help us out of this dilemma in a it is difficult to be a poor consultant. In the comparative way that Professor Scadding does not emphasise. isolation of primary medicine, however, it is all too easy to It is certainly incorrect to regard diagnosis as a static slip back, and a constant vigil is required to maintain and improve standards. process-i.e., as coming to a halt once a disease has been named. In practice, one assembles data continuously on a (d) Satisfaction, intellectual and otherwise, in general practice is strictly in proportion to input. patient and at appropriate intervals compares what one has elicited with one’s store of information about similar cases. We, the primary physicians who know these facts, must Often, the " naming " of the disease is a very unimportant somehow get them over. How? I would suggest by the following means: part of the management of the case. For example, histological evidence of " sarcoidosis " may be come by relatively early (1) Taking every opportunity to teach students.-My partners and I believe that we have been able to show the light " to a handful of in the course of the patient’s illness. Yet one is left with the problem of predicting the course of the illness, and its best students who have since gone into general practice, though their clinical teachers have indicated that they must be devoid of ambition treatment, as these differ so much in different manifestations wish to enter general practice. What is the this so-called disease. for of necessary practising to (2) Striving for the establishment in all medical schools of departclinician is a large amount of recorded experience of cases ments of general practice.-This is where general practice at its with similar clinical manifestations-not just information best can be demonstrated. about the disease. This computers could be made to provide. (3) Educating the educators not to discourage prospective primary As we apply an increasing number of clinical adjectives to physicians.-Many established clinical teachers have no knowledge our patients, so we increase specificity-and, at the same time, of primary medicine. They wrongly believe that they see a true cross-section from their outpatient referrals. As Dr. McWhinney reduce the number of possible cases we may compare them It should be unthinkable for an internist or paediatrician writes: with. Somewhere along the line we will obtain the optimum not to have had part of his training in primary medicine." Let ratio of specificity and available information. To proceed further us hope that the time will come when the holder of a consultant will be to arrive at the reductio ad absurdum of "no-one is quite appointment in any clinical specialty will be required to have had like this patient ". This is an admirably human standpoint, but experience in primary medicine. useless if we are to help him. The dynamic and constantly How are general practitioners to disseminate the necessity changing character of diagnosis in a single case must always be for these reforms to the existing hierarchy ? I suggest there are borne in mind. Possibly a more fruitful approach to this probfour ways. lem will come from topology. At the moment we regard a from students who are enthusiastic about the idea patient as being " placed " in the field of disease by the various of (a) Feed-back medicine. primary adjectives we apply to him. In fact, he is always moving in this (b) If and when departments of general practice are established, field of " multi-dimensional " space-and it may be possible to something is bound to " rub off" and influence other clinical " " " derive formulae to predict his flow-line in this multidepartments. dimensional " space. This approach is already being used in (c) General practitioners must be more prepared to write, discuss, studying the far more complex problems of national economy and lecture on their own subjects. General-practitioner lectures should be included in most postgraduate courses, and more seminars where words and sentences do not suffice to convey the resulshould be held in such courses. (Many of us often learn more on a tant of myriad influences. Perhaps in medicine too, we are due refresher course from our fellow students than from the organised for liberation from the tyranny of words which somehow fail toI correspond to our experience, distort our intentions, and fog course.) (d) By personal contact, phone, letter, or domiciliary consultation, communications. we general practitioners must make it plain that we do in fact speak Above all, work should be commenced now on a nationall the same language as consultants and that we are not in the backscale to collect clinical data on as many patients as possible andl woods of medicine. have it stored in such a way as to make access possible to D. DEAN. inquirers with clinical problems, so that the outcomes of previous cases may be available for study. Ultimately, this would render the whole business of diagnosis and disease recognition obsolete. The classification of illness would again have its roots in reality CONFIDENTIALITY BETWEEN GENERAL and not in the index pages of a medical textbook. PRACTITIONER AND CONSULTANT G. H. HALL. saw a who arrived in "
"
.
"
’
SIR,-I recently psychiatric outpatient litigious and highly indignant mood, having just read the general practitioner’s referral letter which had been handed to her in a sealed envelope. His detailed and helpful report con-
a
MEDICAL STAFFING IN THE N.H.S. SIR,-Iagree with Dr. McWhinney (Oct. 21, p. 885) that Dr. Last’s solution (Oct. 7, p. 769) to this problem by discarding the tripartite structure of the N.H.S. is symptomatic A much more radical change of system and treatment only. of thinking is called for. Dealing with the problem purely from the angle of general practice, or primary medicine as Dr. McWhinney calls it, I believe that there is a great deal which can be done now, which may well help to bring about the revision of the system that is
tained
statements that the home was dirty, that she was an incompetent mother and housewife, and that the children were generally ill cared for and neglected. It also stated that the patient often failed to take her medication and at other times abused it; she was very demanding and frequently asked for
house-calls when these were unnecessary. Much of my interview was taken up with dealing with the patient’s denial of these allegations. The husband also demanded to see me in support of these protestations. It was clear that the patient had been
Letters to the Editor
urgently required. Students and newly qualified doctors acquainted with the following facts:
must be
(1) General practice
can
be
a
stimulating
and
satisfying specialty.
DIAGNOSIS: THE CLINICIAN AND THE (2) Good medicine can be, and is, practised outside the hospital walls. COMPUTER (3) All the " interesting cases " of hospital medicine come from SIR,-I think Professor Scadding’s article (Oct. 21, p. 877) general practice in the first place. illustrates well the struggle of the modern clinician to free (4) There is room for the superior intellect in general practice himself from the constraints of the concept of rigid disease because: entities. Yet without classification, there would be chaos. (a) Cases came to notice much earlier, with fewer physical signs than the consultant sees, and therefore the diagnostic challenge It often seems unreal to squeeze the data appertaining to a is greater. into an But it is necespatient existing diagnostic category. The problems are of infinite variety, and many skills other (b) sary to make at least a provisional diagnosis in order to draw than purely medical ones are called for. on past experience as a basis for prognosis and treatment. (c) With the infrastructure of registrars, housemen, and students I believe computers can help us out of this dilemma in a it is difficult to be a poor consultant. In the comparative way that Professor Scadding does not emphasise. isolation of primary medicine, however, it is all too easy to It is certainly incorrect to regard diagnosis as a static slip back, and a constant vigil is required to maintain and improve standards. process-i.e., as coming to a halt once a disease has been named. In practice, one assembles data continuously on a (d) Satisfaction, intellectual and otherwise, in general practice is strictly in proportion to input. patient and at appropriate intervals compares what one has elicited with one’s store of information about similar cases. We, the primary physicians who know these facts, must Often, the " naming " of the disease is a very unimportant somehow get them over. How? I would suggest by the following means: part of the management of the case. For example, histological evidence of " sarcoidosis " may be come by relatively early (1) Taking every opportunity to teach students.-My partners and I believe that we have been able to show the light " to a handful of in the course of the patient’s illness. Yet one is left with the problem of predicting the course of the illness, and its best students who have since gone into general practice, though their clinical teachers have indicated that they must be devoid of ambition treatment, as these differ so much in different manifestations wish to enter general practice. What is the this so-called disease. for of necessary practising to (2) Striving for the establishment in all medical schools of departclinician is a large amount of recorded experience of cases ments of general practice.-This is where general practice at its with similar clinical manifestations-not just information best can be demonstrated. about the disease. This computers could be made to provide. (3) Educating the educators not to discourage prospective primary As we apply an increasing number of clinical adjectives to physicians.-Many established clinical teachers have no knowledge our patients, so we increase specificity-and, at the same time, of primary medicine. They wrongly believe that they see a true cross-section from their outpatient referrals. As Dr. McWhinney reduce the number of possible cases we may compare them It should be unthinkable for an internist or paediatrician writes: with. Somewhere along the line we will obtain the optimum not to have had part of his training in primary medicine." Let ratio of specificity and available information. To proceed further us hope that the time will come when the holder of a consultant will be to arrive at the reductio ad absurdum of "no-one is quite appointment in any clinical specialty will be required to have had like this patient ". This is an admirably human standpoint, but experience in primary medicine. useless if we are to help him. The dynamic and constantly How are general practitioners to disseminate the necessity changing character of diagnosis in a single case must always be for these reforms to the existing hierarchy ? I suggest there are borne in mind. Possibly a more fruitful approach to this probfour ways. lem will come from topology. At the moment we regard a from students who are enthusiastic about the idea patient as being " placed " in the field of disease by the various of (a) Feed-back medicine. primary adjectives we apply to him. In fact, he is always moving in this (b) If and when departments of general practice are established, field of " multi-dimensional " space-and it may be possible to something is bound to " rub off" and influence other clinical " " " derive formulae to predict his flow-line in this multidepartments. dimensional " space. This approach is already being used in (c) General practitioners must be more prepared to write, discuss, studying the far more complex problems of national economy and lecture on their own subjects. General-practitioner lectures should be included in most postgraduate courses, and more seminars where words and sentences do not suffice to convey the resulshould be held in such courses. (Many of us often learn more on a tant of myriad influences. Perhaps in medicine too, we are due refresher course from our fellow students than from the organised for liberation from the tyranny of words which somehow fail toI correspond to our experience, distort our intentions, and fog course.) (d) By personal contact, phone, letter, or domiciliary consultation, communications. we general practitioners must make it plain that we do in fact speak Above all, work should be commenced now on a nationall the same language as consultants and that we are not in the backscale to collect clinical data on as many patients as possible andl woods of medicine. have it stored in such a way as to make access possible to D. DEAN. inquirers with clinical problems, so that the outcomes of previous cases may be available for study. Ultimately, this would render the whole business of diagnosis and disease recognition obsolete. The classification of illness would again have its roots in reality CONFIDENTIALITY BETWEEN GENERAL and not in the index pages of a medical textbook. PRACTITIONER AND CONSULTANT G. H. HALL. saw a who arrived in "
"
.
"
’
SIR,-I recently psychiatric outpatient litigious and highly indignant mood, having just read the general practitioner’s referral letter which had been handed to her in a sealed envelope. His detailed and helpful report con-
a
MEDICAL STAFFING IN THE N.H.S. SIR,-Iagree with Dr. McWhinney (Oct. 21, p. 885) that Dr. Last’s solution (Oct. 7, p. 769) to this problem by discarding the tripartite structure of the N.H.S. is symptomatic A much more radical change of system and treatment only. of thinking is called for. Dealing with the problem purely from the angle of general practice, or primary medicine as Dr. McWhinney calls it, I believe that there is a great deal which can be done now, which may well help to bring about the revision of the system that is
tained
statements that the home was dirty, that she was an incompetent mother and housewife, and that the children were generally ill cared for and neglected. It also stated that the patient often failed to take her medication and at other times abused it; she was very demanding and frequently asked for
house-calls when these were unnecessary. Much of my interview was taken up with dealing with the patient’s denial of these allegations. The husband also demanded to see me in support of these protestations. It was clear that the patient had been