There I was again at the bedside of a critically ill patient in the ICU. The patient was very sick and in distress. I was challenged to determine what was making him so ill, just like when I was a medical student but now with the knowledge and experience of being a pulmonary physician for 35 years. Nevertheless I felt insecure and stressed until I finally figured out why his pneumonia was not responding to routine antibiotics. Taking more history I found that he had recently visited a hotel with a beautiful fountain spraying in the lobby and I concluded that he had acquired legionnaire’s pneumonia, switched his antibiotics and he promptly got better. I was relieved and the family was thrilled.
As a physician I believe there is hardly anything as professionally satisfying as making the correct diagnosis. Getting the correct diagnosis is pivotal to the patient’s outcome. When we can’t figure it out everyone agonizes. With the correct diagnosis we can proceed linearly to the correct treatment and project a prognosis. This gets us all – patient, family and medical staff – out of the scary realm of the unknown.
The process of getting to the correct answer is complex and requires excluding other competing processes, called the differential diagnosis. The physician must amalgamate a complex array of historical data along with physical examination findings and a constellation of laboratory and X-ray items. We put these together using deductive reasoning, pattern recognition and decision-making guided by previous experience and common sense. The process is fraught with uncertainty as clinical medicine is not an absolute science.
In making the diagnosis we springboard off the efforts of many preceding physicians and scientists and our own hard-won pyramid of knowledge and experience. In so doing we acknowledge the legacy of our professors, mentors, and fellow physicians joining us in the trenches. Exchanging knowledge with colleagues is one of my physicianly joys.
Sometimes making just that extra effort in pursuing the diagnosis can be so rewarding. Consider the patient severely ill from pneumonia of mysterious origin and getting rapidly worse despite several antibiotics. Pursuing further questioning revealed the patient had been exposed to parrots brought into the country without quarantine. I quickly switched to the specific antibiotic for this pneumonia fixing the patient rapidly. What a relief. Then I recall the doctor’s heavy-smoking mother who was getting seriously short of breath and everybody assumed she had irreversible emphysema. Careful history-taking divulged a few clues suggesting asthma also and she responded dramatically to asthma therapy with great relief of her shortness of breath.
So when I can make the correct diagnosis I believe it is both exhilarating and amongst the highest of my functions as a physician.
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