John Wooden, the Hall of Fame UCLA basketball coach from the 60s and 70s, was once asked what major difference, if any, there was between basketball of his time when he won so many championships, and college basketball of today. Without the least bit of hesitation, he said: “The fundamentals”. He said that most basketball players today are more concerned about their fancy jump shots or trick passes rather than proper dribbling skills or just hitting the ball within the backboard square to get it into the net.
 
I think, in this same way, many healthcare professionals have also veered away from what we would call “the fundamentals of medicine”.
 
I still remember like it was yesterday when I was in medical school, being chastised by my medical faculty for ordering “unnecessary” tests. Like me, other residents and medical students were mercilessly grilled during morning rounds, having to justify why a certain test was ordered. Common responses included: " just to see...", or "to rule out condition x". But such responses were just excuses, of course: A crutch to bolster our
novice decision making abilities. One of the basic tenets that got hammered over and over into us by our attending physicians,
and even in text books, was that a test is ordered only if you think that the results could lead to a change in your diagnosis.
fundamentals...continued
 
Yet, being inexperienced, we would still find ourselves using tests to “support” and not to go against our current diagnosis.
 
The Patient’s Medical History

In my mind, tests are secondary to what I think is one of the most basic fundamentals of medicine: Getting a thorough history and a physical exam. Study after study has proven, that in most cases, all these sophisticated tests, or the “bells and whistles” in medicine result in no change in the physician’s original diagnosis—and if and when they do these are the exceptions rather than the norm.
 
Essentially, making a good diagnosis still boils down to the basics. It’s as simple as making eye contact with the patient, and just sitting down to listen to their story (as in medical history). It also means taking the time to perform a good physical examination—yes, all of the “boring” meat and potatos stuff  that you’d normally not see much of in today’s medical dramas like E.R. or Grey’s Anatomy. But I firmly believe listening to the patient and formulating a differential diagnosis, as mundane as that sounds, is the true art and science of medicine.
 
Making the Diagnosis

To summarize, once a patient complains of a primary symptom, a list of conditions instantly goes off in my head, in rank order. Usually the patient will qualify the timing, intensity, duration, aggravating and alleviating factors, and if not, I will elicit for them. At this point, I have narrowed down the differential diagnosis down to one or two possible conditions, or sometimes three. If I have more than one possible diagnosis, I ask about pertinent positives or negatives for each of the remaining diagnoses, to weed out as many on my mind's list as possible. When necessary, going into detail about the patient's past family history or early childhood can contribute significantly.
 
During the entire patient interview (and this is key), I am also observing and making a mental note of the patient's demeanor, body movements, vocal tone, inflection or mood, form of dress and any other "clues" that may help me in making the correct diagnosis. Without really “seeing” the patient in this way, my diagnosis, no matter how scientifically valid, is without context and essentially meaningless.
 
This systematic and complex interview technique was taught as the "Atchley Method" at my alma mater Columbia University. Dr. Atchley was a giant in the field of medicine many decades ago. I'm sure other medical schools still teach a variation of this technique. As for me, it’s an indispensable part of my practice even today.
 
The Physical Exam   
   
The level of detail of the physical examination depends on the complexity of the history and the presenting complaint. Similar to the history taking process, the physical exam is performed to confirm or eliminate each of the possible diagnoses.
 
This is performed by observing or feeling for pertinent positives or negatives attributable to each diagnosis. For instance, if the patient’s history is consistent with the diagnosis of nasal allergies and the examination shows swollen nasal membranes and lots of clear nasal discharge, I will diagnose allergic rhinitis and may recommend avoidance measures with or without medications.
 
Ordering A Test: But Which Test?
 
After a thorough history and examination is performed, and if the proper diagnosis is still unclear, then a test may be in order.
 
Even though ordering tests have almost become rudimentary these days, it didn’t become this way, as some people have come to believe, because the tests are “better” or even more “accurate” at diagnosing the patient than the doctors are. In fact, results yielded can often be more vexing than the problem it’s trying to diagnose.
 
Yes, ordering a test can confirm a suspicion, but in equal measure all tests, by definition, are imperfect. A "good" test will be able to show a positive answer in over 90% of cases compared to a gold standard test. But this also depends on what the gold standard is. Also, even if you don't have a condition, there is always a few percent chance that you may be falsely "positive" even though you are truly negative.
 
This is absolutely the case with radiology tests—especially MRIs (Magnetic Resonance Imaging) and CT (Computed Tomography) scans. Even though CTs and MRIs are extremely useful in helping you visualize what you can’t see with the human
eye, the irony is that these tests can sometimes reveal
much more than what you or even the doctor were looking for. For instance, some patients  come to see me because they had a brain CT for an unspecified neurologic reason, and the CT incidentally showed that the patient had a sinus "polyp". Usually the patient is completely asymptomatic by history, and upon examination, and from previous experience, these  benign growths or swelling of the sinus mucous membrane are due to very nonspecific causes. In fact, one study showed that over 50% of people who just had a simple "cold" had abnormal findings on a CT.
 
Similarly, MRIs are notorious for what radiologists often refer to as UBOs or unidentified bright objects. Sometimes, they can show lesions or growths that can start a patient and doctor on a wild goose chase, invoking more questions than answers. Ultimately, there are no absolute answers to these vague findings. Just the doctors’ educated guesses and the patients’ willingness to trust those opinions.
 
The End Of Medicine As We Know It
 
Yet there’s one opinion which seems to challenge this point of weakness—although I fear this opinion is starting to reflect the moods of the many in this collectively “modern” medical community. Andy Kessler, a former Wall Street hedge fund manager, suggests in his book, The End of Medicine, that without the doctor’s fallibility holding it back, technology will become the crowning glory of modern medicine.
 
His basis for this argument begins with an enamored look at a “computer aided detection” system for mammograms, where a machine aptly named “R2” can make the most seasoned team of radiologists look like The Marx Brothers in that movie classic Duck Soup. He speculates that in the near future, medicine as we know it, and the way I’ve just described above, will pale in comparison to all that technology has to offer patients.
 
Yet, Maggie Mahar in Money Driven Medicine (author of Bull), sees it differently. She writes in one chapter aptly titled “When More Care is Not Better Care” about Lew Silverman-a 75 year old, legally blind, type 1 diabetic who goes into renal failure after spending 5 days in the hospital’s intensive care ward. In response, the renal specialist who’s caring for Mr. Silverman suggests emergency exploratory surgery and thereafter dialysis—A treatment plan which the patient and the patient’s daughter and appointed “health care agent” both declined. Reflecting on the daughter’s perspective, Maggie Mahar writes:
 
“The message was clear: this is what we do. He (renal specialist) was not interested in talking about what Lew Silverman wanted, his quality of life, or what stage of life he had reached.”
 
As it turns out, Lew Silverman, having refused this cutting edge, last chance for life treatment, would miraculously recover just on his own. Then eventually, 12 hours later, he would expire, despite all that modern medicine could do to keep him alive.
 
Yet, society as a whole, rather than focusing on the doctor and his patient, are being lured away more and more by the siren call of modernized medicine. Even I have to admit I’m usually the first one to try the latest and most cutting edge technology when the opportunity arises. As I see it, however, medical technology is nothing more than a better tool or instrument by which we can enhance our performance. It’s just that and nothing more. Once we start to endow it with much more significance, then medicine might as well go the way of the dinosaurs. I think, just as text messaging can never replace a good conversation with a friend over a relaxing dinner, no amount of computer- guided imaging systems, or video stroboscopies can replace that unique, face to face encounter I have with each and every patient every day. This truly is what makes the practice of medicine worthwhile for me, and hopefully for my patients as well. Let us hope never to veer away from this fundamental truth.

West Side ENT