Clinical Diagnosis and Tele Medicine

Ms. Atishaya Kaushal, Advocate

(9891952134/atishayakaushal@gmail.com)

CLINICAL DIAGNOSIS & ARRIVAL OF TELEMEDICINE IN INDIA

1. THE TWO-WAY HUMAN ELEMENT BETWEEN THE PHYSICIAN & THE PATIENT.

The first and foremost tool at the command of the physician is the pair of hands and the pair of eyes that Mother Nature has bestowed upon him. The undergraduate courses of the medical colleges in the curriculum carry the sharpening of visible perception of the subject (patient) … the physical appearance, the tell-tale signs and presentations escalated by the symptomatic jugglery of the disease process, and is magnified into a provisional or conformed positioning or likelihood of the issues which the patient is suffering from, in other words, known as ‘ clinical diagnosis’. 

It is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as clinical diagnosis with the medical context being implicit. The information required for diagnosis is typically collected from a history and physical examination of the person seeking medical care. Often, one or more diagnostic procedures, such as medical tests, are also done during the process.

The diagnostic process proceeds as follows: First, a patient experiences a health problem. The patient is likely the first person to consider his or her symptoms and may choose at this point to engage with the health care system. Once a patient seeks health care, there is an iterative process of information gathering, information integration and interpretation, and determining a working diagnosis. Performing a clinical history and interview, conducting a physical exam, performing diagnostic testing, and referring or consulting with other physicians are all ways of accumulating information that may be relevant to understanding a patient's health problem. Acquiring a clinical history and interviewing a patient provides important information for determining a diagnosis and also establishes a solid foundation for the relationship between a physician and the patient, i.e. the current concern & presentation, past medical history, family history, social history, and other relevant information, such as current medications (prescription-based and over-the-counter purchases) and dietary supplements.

The process of acquiring a clinical history and interviewing a patient requires effective communication, active listening skills, and tailoring communication to the patient based on the patient's needs, values, and preferences.

The course of treatment may start with the accurate diagnosis of the patient, the timely ‘diagnosis’ of the patient, and the skillful picking up of other alerts like the co-morbid conditions. Mis-diagnosis, error in diagnosis/judgment, and sometimes missed diagnosis derails a course of treatment without any intentional lapse on the part of the caregiver. The trajectory of alleged medical negligence steeply goes down where the per capita time spent by the physician with the patient is comparatively more during which there is a random exchange of complaints, conditions, difficulties and problem areas vocally and expressly shared by the patients himself and the rapt attention paid by the physician to hear and listen, see and watch, capture and observe, pickup and apply and make up a firm mind to give the best treatment of choice. There is no rule of thumb or any judicial prerogative that can be used as a benchmark for preventive measures that may be observed by all the doctors during their first encounter with the patients. The academic, practical, on the job training and experience hours, determine the acumen of the intuitive clinical skills. Technology can be at its best or worst but medical professionals shall not impose or subject their patients to unnecessary tests and laboratory examinations unless actually required.

The physical exam is a hands-on observational examination of the patient. First, a physician observes a patient's demeanor, complexion, posture, level of distress, and other signs that may contribute to an understanding of the health problem. If the physician has seen the patient before, these observations can be weighed against previous interactions with the patient. A physical exam may include an analysis of many parts of the body, not just those suspected to be involved in the patient's current complaint. A careful physical exam can help a physician refine the next steps in the diagnostic process, can prevent unnecessary diagnostic testing and can aid in building trust with the patient.

There is no universally agreed-upon physical examination checklist; myriad versions exist online and in textbooks.

Due to the growing emphasis on diagnostic testing, there are concerns that physical exam skills have been underemphasized in current health care professional education and training.

Physicians at Stanford have developed the “Stanford 25,” a list of physical diagnostic maneuvers that are very technique-dependent. Educators observe students and residents performing these 25 maneuvers to ensure that trainees are able to elicit the physical signs reliably.

Over the past more than100 years, diagnostic testing has become a critical feature of standard medical practice. Diagnostic testing may occur in successive rounds of information gathering, integration, and interpretation, as each round of information refines the working diagnosis. In many cases, diagnostic testing can identify a condition before it is clinically apparent; for example, coronary artery disease can be identified by an imaging study indicating the presence of coronary artery blockage even in the absence of symptoms.

Physicians may also refer to or consult with other physicians (formally or informally) to seek additional expertise about a patient's health problem. The consult may help to confirm or reject the working diagnosis or may provide information on potential treatment options. If a patient's health problem is outside a physician's area of expertise, he or she can refer the patient to a physician who holds more suitable expertise. Physicians can also recommend that the patient seek a second opinion from another physician to verify their impressions of an uncertain diagnosis or if they believe that this would be helpful to the patient

Of major importance in the diagnostic process is the element of time. Most diseases evolve over time, and there can be a delay between the onset of disease and the onset of a patient's symptoms; time can also elapse before a patient's symptoms are recognized as a specific diagnosis. Some diagnoses can be determined in a very short time frame, while months may elapse before other diagnoses can be made. This is partially due to the growing recognition of the variability and complexity of disease presentation. Similar symptoms may be related to a number of different diagnoses, and symptoms may evolve in different ways as a disease progresses; for example, a disease affecting multiple organs may initially involve symptoms or signs from a single organ. The thousands of different diseases and health conditions do not present in thousands of unique ways; there are only a finite number of symptoms with which a patient may present. At the outset, it can be very difficult to determine which particular diagnosis is indicated by a particular combination of symptoms, especially if symptoms are nonspecific, such as fatigue. Diseases may also present atypically, with an unusual and unexpected constellation of symptoms.

2.   CLINICAL REASONING/ THE BACKBONE OF CLINICAL DIAGNOSIS

Accurate, timely, and patient-centered diagnosis relies on proficiency in clinical reasoning, which is often regarded as the physician's quintessential competency. Clinical reasoning is “the cognitive process that is necessary to evaluate and manage a patient's medical problems”. Understanding the clinical reasoning process and the factors that can impact it are important to improving diagnosis, given that clinical reasoning processes contribute to diagnostic errors. Health care professionals involved in the diagnostic process have an obligation and ethical responsibility to employ clinical reasoning skills.

 Clinical reasoning occurs within physicians' minds and involves judgment under uncertainty, with a consideration of possible diagnoses that might explain symptoms and signs, the harms and benefits of diagnostic testing and treatment for each of those diagnoses, and patient preferences and values.

When patients present themselves for medical examination, physicians gather information and compare that information with their knowledge about various diseases. This can include comparing a patient's signs and symptoms with physicians' mental models of diseases. This initial pattern matching is an instance of processing. If a sufficiently unique match occurs, then a diagnosis may be made without involvement in secondary processing.

However, some symptoms or signs may not be recognized or they may trigger mental models for several diseases at once. When this happens, gradual processing may be engaged, and the physician will continue to gather, integrate, and interpret potentially relevant information until a working diagnosis is generated and communicated to the patient. When this process triggers pattern matches for several mental models of disease, a differential diagnosis is developed.  Based on their knowledge base, physicians then use deductive reasoning: If this patient has disease A, what clinical history and physical examination findings might be expected, and does the patient have them? This process is repeated for each condition in the differential diagnosis and may be augmented by additional sources of information, such as diagnostic testing, further history gathering or physical examination, or referral or consultation. The cognitive process of reassessing the probability assigned to each potential diagnosis involves inductive reasoning, or going from observed signs and symptoms to the likelihood of each disease to determine which hypothesis is most likely. This can help refine and narrow the differential diagnosis. Further information gathering activities or treatment could provide greater certainty regarding a working diagnosis or suggest that alternative diagnoses be considered. Throughout this process, physicians need to communicate with patients about the working diagnosis and the degree of certainty involved.

Novice physicians and medical students are more likely to rely on analytical reasoning throughout the diagnostic process compared to experienced physicians  Expert physicians possess better developed mental models of diseases, which support more reliable pattern matching. As a physician accumulates experience, the repetition of processing can expand pattern matching possibilities by building and storing in memory mental models for additional diseases that can be triggered by patient signs and symptoms. The ability to create and develop mental models through repetition explains why expert physicians are more likely to rely on pattern recognition when making diagnoses than are novices—continuous engagement with disease conditions allows the expert to develop more reliable mental models of disease—by retaining more exemplars, creating more nuanced prototypes, or developing more detailed illness scripts.

I MAY CONCLUDE, THEREFORE THAT CLINICAL DIAGNOSIS BY PERSONAL AND PHYSICAl  INTERACTION BETWEEN THE PATIENT AND THE PHYSICIAN IS AN INDISPENSABLE FEATURE AND BUILDING BLOCK OF ANY TREATMENT.

JUST AS SCIENCE & TECHNOLOGY HAS DEVELOPED DIAGNOSTIC TOOL, THE  “VIRTUAL CLINIC” it could be the thing of the future, that shall require inputs and contribution from the patients, physicians and all other stakeholders in the industry. But, man-made computers and not vice versa, the man also made robots, and not vice versa. Humans will continue to treat and cure humans!