Is diagnosis a word

1. Jeffrey K Aronson

1. Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford

1. Twitter @JKAronson

An aphorism

I have previously suggested that an aphorism attributed to William Osler, “Listen to the patient; he is telling you the diagnosis,” did not originate with him.1 Perhaps he said something like it and someone else modified it. Or perhaps someone else coined it and passed it off as Oslerian to give it more cachet.

Whatever the source, is the aphorism true? When patients tell their stories are they telling you the diagnosis? Well it depends in part on how much they tell you and in part what you mean by “diagnosis.” Here’s an example.

A 54 year old man tells you the following story. “I was running upstairs at home and suddenly developed crushing retrosternal pain. It radiated up to my neck and down my left arm. I had tinging in the fingers of my left hand. I had a cold sweat and a feeling that I was going to die.”

Diagnosis

The word “diagnosis” is a direct transliteration of the Greek word διάγνωσις, from the verb διαγιγνώσκειν to distinguish or discern, to know one thing from another. The verb in turn derives from the prefix δια-, which means through, throughout, or right through, implying thoroughness, plus γιγνώσκειν to learn or to know, typically by reflection or observation. Thus, a diagnosis implies thorough knowledge of the condition being diagnosed.

The Oxford English Dictionary defines “diagnosis” as “Determination of the nature of a diseased condition; identification of a disease by careful investigation of its symptoms and history; also, the opinion (formally stated) resulting from such investigation.” The definition is, or appears to be, incomplete. The presenting symptoms and the history of the complaint, which is what the definition mentions, are not the only features invoked in reaching a diagnosis; observation, physical examination, and relevant investigations of different types are also important. One could interpret the term “careful investigation” in the definition as implying those actions, but it would have been better had they been specified.

The English word “diagnosis” is first attested in 1681, in Samuel Pordage’s Table of Hard Words, which he appended to an English translation of some of Thomas Willis’s medical works: “Diagnosis, dilucidation, or knowledg [sic].” A dilucidation is a clarification or explanation. Before that, the word was widely used in medical Latin. Here, for example, is an extract from Chapter 1 of Methodus Univeralis ad Prognosin et Crises Omnium Morborum, sed Praecipue Acutorum Conferens (1628) by André Laurent: “Tria in morbo Medico diligenter adverrenda docet Galen, mille in locis, διάγνωσιν, πρόγνωσιν & θεραπείαν. … Diagnosis circa tria versatur, morbi scilicet, caussae morbificae & affectae partis notitiam.”

So, what’s our patient’s diagnosis? Well, it’s obviously most likely to be a heart attack, or a myocardial infarction, to give it a more technical description. But is that the whole diagnosis—a thorough description? Perhaps it’s an ST segment elevation myocardial infarction, a STEMI. We won’t know until we see an electrocardiogram. Perhaps it’s a STEMI due to plaque rupture in the left anterior descending coronary artery. Angiography will help. And perhaps it’s a STEMI due to plaque rupture in the left anterior descending coronary artery associated with some type of familial hyperlipidaemia.2 We need to know the family history and ask for biochemistry.

Whichever of these it is, if any, we’re not going to get the complete diagnosis from the patient’s story, even if our 54 year old man is able to reproduce the story outlined above unprompted, which is highly unlikely. What he’ll probably say is that he got chest pain after running upstairs. The other details, the nature of the pain, its pattern of radiation, and the other associated features, will emerge only after careful questioning.

Eliciting the history

It has been suggested that the traditional method of teaching students how to elicit a patient’s history is outmoded and should be replaced by simply listening to the patient.3 The assertion is that “we should now abandon the idea of taking a history altogether and talk only about listening to people’s stories.” Instead of starting with questions such as “What is the problem that brought you into hospital?” you ought to begin with “Would you mind telling us about yourself?” My response to such a question might go as follows: “Well, I’m a physician, a clinical pharmacologist actually. I trained in Glasgow but I’ve worked in Oxford for nearly 50 years. I’m currently in the Centre for Evidence Based Medicine, doing teaching and research, and my main interests …” “No, no. Sorry. What’s the problem that brought you into hospital?” “Oh, I see. Well, I’ve got this pain in the chest …”

Of course we should listen to what the patient is telling us. Of course we should be less formal and “engage with [the patient] as a person and not relate solely to [their] demographic data, symptoms or pathology,”3 but the questions still need to be asked, and too much informality can be counterproductive and may, it has been suggested, generate uncertainty and misunderstanding.4

Learning the medical tables

Consider the problem of long multiplication when your calculator isn’t working. How are you going to calculate the product of, say 43 and 47? You’ll probably start by writing it down:

43

×47

Then you’ll multiply 43 by 7 (301); then 43 by 4, having first written a zero in the units column (1720):

43

×47

301

1720

Then you’ll add the two products: 301+1720=2021.

The first computation you did was to multiply 3 by 7. How did you do it? I’m sure you didn’t think “one seven is seven, two sevens are fourteen; three sevens are twenty one.” No. You got “twenty one” almost without thinking, because you learned your seven times table at school, by rote.

Learning to take a clinical history is like that. You learn your cardiovascular table by rote, your respiratory table by rote, your gastrointestinal table by rote, and so on. It’s like so many other things that you learn by rote in medicine. But after some time you start to adapt your rote learning in taking the history; you don’t go through it all by strict rote any more than you conscientiously repeat your seven times table to calculate 3 times 7. Instead, you tailor your questions to the patient’s preliminary account. This is reflected in the way that different styles of questioning may elicit different stories. Most, if not all of us will have observed the discomfiture experienced by a junior doctor when the history later elicited by the consultant differs from the original story the junior doctor recounted.

A 63 year old man comes to your surgery to ask about the fact that his little finger is starting to curl up towards the palm of his hand. In this case you’d probably examine it before asking any questions at all, another variant on the process. It’s Dupuytren’s contracture. You might think of asking him what his occupation is—perhaps he uses vibrating instruments.5 You’ll also ask him questions relating to his drinking habits, thinking about chronic liver disease,6 and ask about symptoms of diabetes mellitus.7 A family history may also be of interest. But those wouldn’t be the questions you would put to a 35 year old woman who came wondering why she’d missed a menstrual period. In neither case will the patient’s story tell you the diagnosis; judicious questions are needed. When multiplying 56 by 89 the seven times table won’t help.

No patients will ever give you a detailed description of the acute myocardial infarction or other condition that they are experiencing. They will tell you the bare bones. The rest needs to be elicited by careful use of appropriately framed questions. To suggest that teaching how to take a history by rote is outmoded is fallacious. The patient’s tale and the questions you ask, and the way you ask them, are complementary. They combine to form the narrative that leads you to a provisional set of diagnoses that can then be tested by careful observation, physical examination, and relevant investigations.

William Osler knew all this: “We expect too much of the student and we try to teach him too much. Give him good methods and a proper point of view, and all other things will be added, as his experience grows.”8

Footnotes

• Competing interests: None declared.

• Provenance and peer review: Not commissioned; not peer reviewed.