The most vital skill any doctor can have ... LISTENING
BOTH patients and young doctors like diagnostic tests — blood tests, of course, but also tests that let you see inside the body, such as scans.
If you have persistent bladder problems or acid reflux (heartburn), for instance, then the chances are that at some point a relevant specialist will have put an endoscope — a flexible tube with a camera on the end, of which there are many types — inside you to have a look around.
An over-reliance on such technology, however, means that if a test comes back clear, some doctors, particularly younger ones, will say there is no illness and then be at a loss as to how to manage the symptoms. The result is an undiagnosed and potentially more distressed and worried patient.
We should not forget the old-fashioned approach to medicine, where you spend time listening to the patient’s problems and working out how best to help them.
As a gastroenterologist, I understand why patients want tests. Take irritable bowel syndrome (IBS); there are thousands of people whose symptoms are extreme and debilitating. By the time they come to me, they will have already had a couple of colonoscopies (an examination of the intestine), but want further tests, such as an MRI scan, because they are convinced that something has been missed.
Modern gastroenterologists, wanting both to keep patients happy and fearing they will be for the high jump if they miss something as sinister as cancer, are very inclined to ‘scope’ and scan.
It was very different in pre-war days. Physicians did not have all these gadgets and technologies. Instead, the emphasis was on talking to patients, honing the bedside manner and communicating with them effectively.
They would run through the symptoms and come up with a diagnosis based on the patient’s story and treat them on that basis.
Younger doctors don’t feel so comfortable doing that. And the problem with all these modern diagnostic technologies — scopes, X-rays, CT scans, MRIs and so forth — is that there are conditions that they simply cannot detect.
Put simply, tests are not the be all and end all. And it is inadvisable to rely on them at the expense of good old-fashioned doctoring skills and diagnosis.
This is particularly true with ‘functional conditions’, where there are very real symptoms but no structural abnormalities that will show up on a scan such as irritable bowel syndrome.
We don’t entirely know what is going on with IBS, but it is thought to be related to an oversensitivity in the gut. We also know that IBS patients’ bowel muscles contract more strongly, causing a spasm-type pain, but there are no abnormalities that can be detected by any test.
Consequently, patients can be caught up in a cycle of fruitless testing. And, ultimately, the doctor tells the patient: ‘I can’t find anything wrong with you. Everything is normal, or it might just be IBS.’ But that word ‘normal’ is a problem. I learned very early on in my career that if you bounce up and tell an IBS patient: ‘Good news! Your colonoscopy is normal!’ you will quickly see their face drop.
They do not want to know what is not wrong with them. They want a proper diagnosis, to have their symptoms legitimised and taken seriously.
I don’t have an issue with these investigations per se — it is practising safe medicine after all. But once you have ruled something out, it is pointless to keep doing tests.
I don’t do very many because, often, they don’t provide the answers. If I do feel that one is required, the conversation I have with the patient beforehand is crucial. I will explain that, if I am right, it will be negative, and that means the problem is IBS, a legitimate and often horrible condition. Then we will do our best to help them manage it. I’ll be upfront, explaining that I’m not going to be able to cure them, but that if we can give them a 50% improvement, it means we are doing well.
Sometimes just listening to patients talk uninterrupted for ten minutes can make them feel a bit better. My field is not the only one where the enthusiasm for tests can be problematic — every branch of medicine has its ‘functional conditions’.
FOR rheumatologists it’s fibromyalgia, where the joints are very painful, but when you do scans they look normal. Cardiologists have something called non-cardiac chest pain. It is thought to be down to an oversensitive gullet going into spasm, but the symptoms are identical to angina and patients often repeatedly go to A&E, panicking that they are having a heart attack, but each time a scan shows nothing is wrong.
Of course, you would be mad not to investigate someone with chest pain. The problem is that a third of people with this symptom will have nothing structurally wrong. Similarly, you would be foolhardy not to fully investigate a patient you fear has, say, breast cancer.
I’m not knocking these modern technologies; it is just vital that we retain our old skills as we learn the new ones.
PETER WHORWELL is a professor in medicine and gastroenterology INTERVIEW by DIANA
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