Difficult cases

Over the last year a lot of people I know, some research scientists, some friends and relatives, have suggested to me that doctors should be allowed (and in their opinion would prefer to) concentrate on the more ‘difficult’ or ‘severe’ cases, leaving patients or pieces of tissue with ‘straightforward’ diseases to be diagnosed by somebody else (they never suggest who).

There are two assumptions being made here: the first that it is immediately obvious which are the straightforward and which are the complex cases; the second that doctors only want to deal with the complex cases.

The first assumption, that the severity/complexity or straightforwardness of the case is obvious from the start is completely wrong. This distinction is only possible after the diagnosis has been made correctly. For example:

A 55 year old man wakes up in the night with anterior chest pain – heartburn or heart attack?

A 6 year old girl complains every morning that she can’t go to school because she feels sick and has a headache, by the evening she always seems better – school refusal or brain tumour?

A 60 year old woman has felt tired all the time for weeks – depression or bacterial endocarditis?

Making a diagnosis is a difficult task that requires the skills of history taking to establish what has happened to the patient, examination to assess the patient’s physical condition and a broad knowledge of the conditions that might be causing the patient’s problems. I recall as a medical student spending up to an hour struggling to get an adequate and useful history. As a junior house officer I could take a history and examine a patient in around 30 minutes. The registrar could make a better job of it in 15 to 20 minutes and the consultant could extract the relevant history and the clinical signs even faster. It takes years of training and experience to do this. And even then, based on the history and examination, some more tests relevant to the patient’s condition are often needed to establish what is wrong.

The second assumption is that doctors don’t want to see patients with straightforward problems, or that pathologists don’t want to see normal biopsies (how do you know it is normal beforehand?). A lot of straightforward cases can be rewarding to treat – healing the sick, however ‘simple’ the problem, is the whole point of being a doctor. Even for a pathologist, diagnosing normal tissue can be a joy when you know the alternative diagnosis being considered was cancer. A second point in pathology is that seeing normal tissues and common problems helps us keep a handle on what normal tissues and normal variants look like. If we can’t recognise a normal tissue what hope is there of spotting an abnormal one?

Both of these assumptions are wrong. The irony in this situation is that these assumptions and the deduction that doctors do not need to see ‘simple’ cases are made by people who have never had to make a medical diagnosis in their lives.