Diagnosis: eyes first and most – surely ears are next?

Diagnosis is “eyes first and most, hands next and least” – according to Neel Sharma, writing in the BMJ.

I think, though, that ears come a close second.

Sharma titled his piece courtesy of Sir Lancelot Spratt (played by James Robertson Justice in the film Doctor in the House). And Spratt is indeed explicit about eyes first, hands next. I’m sure Sharma is not altogether advocating the Spratt approach. After all, if you watch all of the suggested video, Spratt says “tongue not at all”. As well as telling the poor patient that “you won’t understand our medical talk”.

It’s not a new idea that ears are important.

Osler said “Listen to the patient, he is telling you the diagnosis”.

I’d go further. When the patient tells the doctor their story, I think he or she is often also telling the doctor a lot about the management. Does this patient simply need to tell their tale? Do they want a strictly medical approach? Or do they have other – and often very specific – ideas?

Sharma’s article helpfully underlines the importance of the traditional clinical skills of looking, palpating, percussing and auscultating (listening with a stethoscope). I wish, that he’d added some more primary care examples of the value of observing. And not only for specific medical diagnoses. But for more of the so-called ‘soft’ and mental health diagnoses that cause so much pain to patients – and doctors too.

One way forward would be to move right away from the idea of ‘taking’ a history.

‘Taking a history’ is what I was taught to do in medical school. But now, as a patient, I know just how annoying / frustrating / infuriating / throughly unhelpful it is for a clinician to ‘take’ my history. They may have ticked all their boxes. But they often (actually, it’s usually) have no idea about my concerns or ideas. So, their ideas about what should happen next are of very little help to me.

Of course there are some important exceptions. The patients who don’t think their exercise-induced left sided chest pain is anything to bother about, for example.

But surely the point of a patient consulting a doctor is not to fit that individual into the set-up of the clinician’s clinic? I think that even the idea of a clinic ‘belonging’ to a clinician is wrong. Sharma ends his piece by agreeing with Sir Lancelot Spratt’s thoughts on success: “you need the eyes of a hawk and the heart of a lion.”

The eyes of a hawk must be a good idea. But the heart of a lion?

It’s another sort of bravery that’s needed to stand beside the huge number of individuals and families living with chronic and life-limiting conditions.


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