Robert B. Taylor
Ten minutes for diagnosis? Really?
Yes, really!
If only we had 90 minutes to perform a diagnostic evaluation, as we did as third-year medical students on hospital rotations. Or, if we even had 30 minutes for diagnosis, as I recall from internship. But those days are gone. Today—as clinicians practicing in the age of evidence-based, cost-effective healthcare—office visits are of much shorter duration than in years past. For example, in a recent study of 4,454 patients seeing 138 physicians in 84 practices, the mean visit duration was 10 minutes (1). Another study of 19,192 visits to 686 primary care physicians estimated the visit duration to be 16.3 minutes (2). Even when the total visit duration exceeds 10 minutes, the time actually devoted to diagnosis—and not to greeting the patient, explaining treatment, doing managed care paperwork, or even the patient’s dressing and undressing—is seldom more that 10 minutes.
So, if you and I generally have only 10 minutes per office visit for diagnosis, we need to be focused, while remaining medically thorough and prudent. Actually such an approach is possible, and is how experienced clinicians tend to practice. The following are some practice guidelines to the 10-minute diagnosis (Dx10). And, to illustrate, let us consider a patient: Joan S., a 49-year-old married woman in your office for a first visit whose chief complaint is severe, one-sided headaches that have become worse over the past year. (For a more complete approach to the diagnosis of headache, see Chapter 2.7.)
Note how the patient relates to the staff, takes off a jacket, and sits in the examination room. How does the patient begin to describe the problem and what does he or she seem to want from the visit? Who accompanies the patient to the office and who seems to do the talking?
Be sure to use “tell me about” open-ended questions. The inexperienced clinician moves early to closed-ended “Yes” or “No” questions, but the veteran Dx10 clinician has learned that using narrow questions too early can lead to misleading conclusions, which, at least in the long run, are wasteful of time and, at worst, dangerous. An example would be inappropriately attributing chest pain to gastroesophageal reflux disease because the patient has a past history of esophageal reflux and responds affirmatively to questions about current heartburn and intolerance to spicy foods.
Watch the facial reaction to issues discussed. Tune in to hesitation and evasive answers, and be willing to follow these diagnostic paths, which may lead to the otherwise hidden problems such as drug abuse or domestic violence. In the case of Joan S., does she answer questions readily, or does she seem evasive when addressing some topics, such as family concerns or her home life?
I remind medical students of the time-honored aphorism that “the most common problems occur most commonly.” When working with a patient, the physician develops diagnostic hypotheses early in the encounter. When faced with a patient with headache, we should initially consider tension headache and migraine rather than temporal arteritis. Of course, the Dx10 clinician thinks of special concerns, such as the possibility that the headache patient might possibly have a brain tumor. The initial history seeks the characteristics and chronology of the symptoms. Then the clinician uses selected questions that help to rule in or out the diagnostic hypotheses: “What seems to precede the headache pain?” “Has the nature or the severity of your pain changed in any way?” The clinician also seeks important past medical, social, and family history: “What stress are you experiencing that may be influencing your symptoms?” “Does anyone else in your family have a headache problem?”
The physical examination should be limited to the body areas likely to contribute to the diagnosis, and a “full physical examination” is actually seldom needed. Thus, for our patient with recurrent headaches, Joan S., the Dx10 examination is likely to be limited to the vital signs, head, and neck, with a screening of coordination, deep tendon reflexes, and cranial nerve function. Examination of the chest, heart, and abdomen is unlikely to contribute to the diagnosis.
Tests should be limited to those that will help confirm or rule out a diagnostic hypothesis or, later, those that would help make a therapeutic decision. For most patients with headache as a presenting complaint, no laboratory test or diagnostic imaging is needed.
Of course, the uncommon problem occurs sometimes. Occasionally, you will encounter the unexpected finding: the headache patient with unanticipated unilateral deafness or the fatigued person with an enlarged spleen. Stop and think when you note a cluster of similar unexpected findings; such alertness helped clinicians identify the Muerto Canyon virus as the cause of the 1993 outbreak of the hantavirus pulmonary syndrome in the southwestern United States and also the occurrence of primary pulmonary hypertension in patients using dexfenfluramine for weight control. A few times in your career you will have the opportunity to experience a diagnostic epiphany; the Dx10 clinician will seize this opportunity by staying alert for the unexpected diagnostic clue.
In addition to your professional knowledge, experience, and time, your diagnostic resources include your staff, the patient and family, and the vast array of medical reference sources available.
Your office and hospital staff can be valuable allies in determining the diagnosis. Important clues may be offered when the patient calls for an appointment or when being escorted to the examination room. If a patient remarks to the receptionist or nurse that his chest pain is “just like my father had before his heart attack” or if another wonders if her heartburn could be related to her 15-year-old daughter’s misbehavior, the staff member should ask the patient’s permission and then share the information with the physician.
The patient and the family generally have some insight into the cause of symptoms such as fatigue, diarrhea, or loss of appetite. In a study of the patient’s differential diagnosis of cough, Bergh found that while physicians considered a mean of 7.6 diagnostic possibilities, patients reported a mean of 6.5 possibilities, with only 2.8 possibilities common to both (3). Joan S. and perhaps her family may offer diagnostic suggestions that you have not strongly considered; also, these other hypotheses represent concerns that should eventually be addressed in order to provide reassurance. For example, might Joan be in the office today chiefly because an old friend has recently been diagnosed with brain cancer and she has become concerned about the significance of her own headaches?
To continue the case of the patient with headache, a migraine diagnosis is incomplete if it fails to include the contribution of marital or job stress to the symptoms as well as the impact on others of family event cancellations, trips to the emergency room, and large pharmacy bills for sumatriptan injections. No diagnosis of cancer or diabetes is complete without considering the impact on the patient’s life and the lives of family members (4).
The Dx10 clinician will be especially wary of ICD-9 (International Classification of Diseases, 9th ed.) diagnostic categories, which facilitate statistical analysis and managed care payments, but which lack the richness of narrative and also the personal and family context. For example, compare “diabetes mellitus, uncomplicated, ICD-9 code 250.00” with “type 2 diabetes mellitus in an elderly patient with poor diet, marginal retirement income, and isolation from the family.”
Failure to consider the psychosocial aspects of disease invites an incompletely understood or even a missed diagnosis: How many instances of child abuse have been overlooked as busy emergency room physicians care for childhood fractures without also exploring the cause of the injury and the home environment?
In eliciting a medical history from Joan S., it will be important to learn the current stresses at work and at home, and how she thinks her life would be different if the headaches were gone.
Today, healthcare, including diagnosis, must be “evidence-based” and not grounded in anecdote or even in your “years of clinical experience.” The evidence is, of course, the vast body of medical knowledge, including research reports and metaanalyses found in clinical journals (5), on the worldwide web (6), and in reference books such as The 10-Minute Diagnosis Manual. In thinking about Joan S., you might search the literature for recent articles on the approach to migraine headaches.
Help is also available from colleagues. Consider a consultation when you have a diagnosis that is somehow not “satisfying.” A personal physician in a long-term relationship with a patient can develop a blind spot and the diagnosis may be apparent only to someone taking a fresh look. What is needed at such a time may be a rethinking of the problem—almost the antithesis of continuity.
Help can be available from the same-specialty colleague down the hall or from a subspecialist.
You do not always need to make the definitive diagnosis on the first visit; in fact, such an approach tends to foster prolonged visits, excessive testing, overly biomedical diagnoses, and high cost medicine without adding quality. When faced with an elusive diagnosis, the best test is often the passage of time and a follow-up visit. For example, we all know that headaches often are influenced by stressful life events. Yet, a new patient may not be ready to share his or her personal, often embarrassing, burdens, and it is only when a trustful relationship has been established that the clinician learns about the abusive spouse, the pregnant teenager, or the impending financial disaster.
Often it is useful to use the descriptive, categorical diagnosis, and seek the definitive diagnosis over time. Examples include the teenage girl with chronic pelvic pain, the young adult with cough for 3 months, the middle-aged person with loss of appetite, and the older person with fatigue or insomnia. Sometimes, on an initial visit, this approach is the only reasonable option.
The Dx10 clinician will be careful not to “fall in love” with the initial diagnosis, and realizes that the depressed patient losing weight might also have cancer and that it is too easy to attribute all new symptoms to a known diagnosis of menopause or diabetes mellitus. If Joan S.’s headaches fail to respond as expected over time, you may wish to reconsider your original diagnosis and perhaps seek further testing that would have seemed excessive on the initial visit. For example, might the “1 year” duration of increased severity merit imaging if a favorable response to initial therapy does not occur?
In your daily practice, use the time saved in the steps described here to consider and reconsider your diagnoses—as you review chart notes, read medical journals, search medical web sites, and see the patient in follow-up visits. The Dx10 clinician will remain open to rethinking the patient’s diagnostic problem list. In the end, patience and perseverance—often measured in 10-minute aliquots over time—will yield an insightful, biopsychosocially inclusive, and clinically useful diagnosis.
1. Stange KC, Zyzanski SJ, Jaen CR. Illuminating the black box: a description of 4454 patient visits to 138 family physicians. J Fam Pract 1998;46:377–389.
2. Blumenthal D, Causino N, Chang YC. The duration of ambulatory visits to physicians. J Fam Pract 1999;48:264–271.
3. Bergh KD. The patient’s differential diagnosis: unpredictable concerns in visits for cough. J Fam Pract 1998;46:153–158.
4. Taylor RB. Family practice and the advancement of medical understanding: the first 50 years. J Fam Pract 1999;48:53–57.
5. Richardson WS, Wilson MC, Guyatt GH, Cook DJ, Nishikawa J. User’s guide to the medical literature: how to use an article about disease probability for differential diagnosis. JAMA 1999; 281:1214–1219.
6. Hersh W. A world of knowledge at your fingertips: the promise, reality, and future directions of on-line information retrieval. Acad Med 1999;74:240–243.
Review other book chapters online related to Over-diagnosed conditions:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X 
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