Translational Medicine & Clinical Diagnosis: Diagnosis and the Physician’s Laboratory

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The curriculum renewal committee of the University Of Washington School Of Medicine[1] offers suggestions for curriculum changes that would enhance the numbers of graduates choosing a primary care specialty. Notably the report did not mention the issues of prestige nor the availability and training in the use of diagnostic tools for a primary care setting.

From a clinical viewpoint primary care is more of a science not less of one than the other more limited specialties. The training and clinical tools should match the challenge and they do not. Medical students need both the tools and the training to do serious diagnostic studies. Contrary to the image of a doctor making a snap diagnosis wherein the only problem is the treatment protocol, diagnosis is multifaceted and no simple matter. Multiple conditions, individual patient constitution, and multiple layers of symptoms compound the challenge. Many studies suggest a high percentage of missed and wrong diagnoses, 35.8% in this study.[2] We use to have the autopsy as a final arbitrator of diagnosis but no more. Autopsy has gone out of style; it is not profitable enough. Some medical schools have abandoned the microscope in favor of digital images in training. The microscope, however, remains one of the most essential diagnostic instruments. Today’s microscope should provide polarized light, dark field and fluoroscopy. This is real-time microbiology.

Historically, medical science advanced through the evolution of diagnostic tools and techniques. First, there was the autopsy, then the stethoscope, and the microscope, then statistics, the x-ray machine, ultrasound and more recently bio-molecular science. Today, hospitals excuse the autopsy with reliance on the CT scan. Largely the CT scan replaces the plain old x-ray. This is not progress. Today the stethoscope hangs around the neck unused. Offices send out most lab work, either to a reference lab or to the hospital. It should be obvious that the primary care doctor needs a small clinic version of all of the basic diagnostic tools and some that exist only in research labs. Basic equipment should include ultrasound, microscope, x-ray, and the skills to go with them. Looking to the future, the primary care physician needs to link current clinical research with his or her practice, especially in statistics and genomics. Polymerase Chain Reaction (PCR)[3] should find common use in the clinic; students should have enough undergraduate experience in proteinomics to manage it.

Many frustrations to the practice of good medicine come from outside the profession. These distortions, accepted as the way things are, limit both the role of the physician and his or her ability to diagnose conditions at hand. For instance, EPA limits a physician from conducting many laboratory tests in the doctor’s office, or requires burdensome licensing and exemptions.[4] While well intended to improve quality and control costs, it does the opposite. One fear suggests that physicians do laboratory studies because they produce more revenue. Perhaps some do, but the unintended consequence denies access to simple inexpensive tests. These tests done in real-time, while the patient is present, save time, save money and improve outcome. A trip to the hospital, results in delay and a much more expensive procedure. I cannot imagine a physician doing a gram stain, a peripheral blood smear, stool, a urine sediment, a sedimentation-rate or a culture and sensitivity for the money; although, payment for these services must cover the cost of time and equipment. Some of the tests are time and space sensitive with unstable chemicals and fragile structures, so inaccuracies accrue when the specimen is sent out.

The same argument can apply to office x-ray. The office machine requires the same inspections and calibrations as in the hospital. The machine may be identical. One does not have to use much imagination to see a political undercurrent persuading legislators that everything must be done in the hospital. Unfortunately, hospital profit motivates the lobbying.

In 1998 while on the Board of Directors of the South Peninsula Hospital, I attended a dinner seminar set up by the network of Alaska hospitals including legislators presumably for educational purposes. It had only begun when it became evident that this meeting had the primary agenda of promoting a bill prohibiting office x-ray machines. The program presented undocumented evidence that office x-ray machines were sub substandard and hazardous while hospital machines were new and operated by licensed technicians. Presenters built a case for eliminating office x-ray machines in favor of securing all x-ray business for hospital radiology units. I was sitting at a table next to Senator Murkowski. He turned with a questioning look. I simply compared the cost of flying a patient from a native village to an Anchorage hospital for an x-ray of the chest in order to assess a clinical pneumonia. The unfavorable cost and the poor medical treatment of a time sensitive illness delayed by a trip to the hospital were obvious. The bill did not pass. In today’s environment, a hospital x-ray becomes a CAT scan. The cost is a hundred fold greater and the information only marginally better. The accumulated CT radiation expositor falls into the danger zone.[5] Students should learn the physics of radiology, quantum physics and participate in research for the newer less toxic photonics.

In short, the primary care doctor should be educated as a scientist in the tradition of the great physicians, past and present. He or she needs the tools of science and of diagnosis and be expert in their use. One wonders, just what is the character we strive towards in a primary care physician? Do we want a doc who is indeed a scientist with the humanity of Hippocrates? Or, do we want a Feldsher with an unused stethoscope hanging indolently around the neck?