342
Journal of the Royal Society of Medicine Volume 85 June 1992
The Sherlock Holmes paradigm detectives and diagnosis: discussion paper
Joel Wilbush DPhil FRCOG
Department of Anthropology, University of Alberta, Edmonton, AB Canada;
Keywords: Sherlock Holmes; medical encounter; social evaluation; diagnosis; behavioural disorders
Introduction Many of the factors which have contributed to the immense popularity of the detective novel, and Sherlock Holmes, paradoxically remin 'an unsolved mystery'. Interpretations abound, but none fully accounts for the undiminished enthusiasm of so many for this genre of literature, nor for the recurrent impact of Sherlock Holmes. The master-detective is especially associated 'with the medical world, (for) three physicians - two real and one fictional - actually help shape and define him'". The readers' friend, the fictional Dr Watson is, at best, but a literary device. Dr Conan Doyle is more author than physician, and often, as students of Holmesiasia attest, a careless one. He is also guilty, as a recent paper2 points out, of distortion of reality: for no solution of a complex murder or clinical case is accomplished pursuing a unilineal course. Investigations follow different levels of enquiry: some succeed, others not, many clues leading nowhere. Only an author can lead the hero to the right clues in the right order -for he alone has glimpsed the picture of the completed jig-saw puzzle2. Dr Joseph Bell, whose clinical approach has served as a model for the Holmesian method, is the most interesting -and the least understood. This is not surprising, for even Dr Bell himself did not really comprehend the processes by which he reached his conclusions. Doctors and detectives The detective novel deals with murder, one of the oldest themes to concern mankind. Concurrently it glorifies the most recent of humanity's advances, modern science. Thus viewed, it paraphrases in modern terms the eternal theme ofthe struggle between good and evil, between ratiocination and ignorance, left-cerebral-hemisphere logic and subcortical, even right-cerebral, impulsive behaviour. It is the power of science to deduce who is the killer, identify the pathogen, which has attracted doctors, who feel a kinship with the rationalistic heroes of the detective novel. Diagnosis, as many students are often told, is exciting, like the action in a detective novel. It is this fascination with the power of science which has allowed not only the 'forgetting the distinction between (fiction) and reality', 'coincidence' or 'many levels and open ends' of diagnostic investigation2, but worst of all, the clinical situation. Though regularly concerned with the emotional or other accounts of witnesses, the focus of detective investigation are the physical remains, the clues to the crime. The clinical encounter, on the other hand, centres on the patient, and however wide it ranges it must return to the patient and her treatment. Detectives are engaged in objective exploration:
doctors, even specialized biomedical operators, are participating in a social process.
Medical problem solving Dr Bell's demonstrations of the;power of observation and deduction to establish many of the non-medical aspects of patients' lives were unusual but,-obviously, both enttaining and effective in impresing studets with the importance of attention to detail. A much more widespread histrionic prop, routinely employed by many more medical teachers and practitioners, is spot-diagnosis. This allows not only oneupmanship, but also adds interest to subsequent explanation of the proces by which it was putatively reached. Today, however, it is frowned upos; probably not so much because not too rarely it proves iaccurate, but mostly because of a feeling that it does not satisfy scientific standards of diagnoais.Yet, research in medial p Qblem solving has shown that not only 'spot' but most clinical diagnoses are 'instantaneous'. Surpingly, it has also demonstrated that the difference between expernenced physicians and relative beginners is, alost isignificant. The average physician reaches a diagnosis in approximately 30 seconds, an expert takes, less, but even a comparatively recent graduate can make it in under one minute3. The epitemological interpretation proposed by this research disappointingly does not greatly differ from that offered by Dr Bell over a century ago. It rests on ripid -observation and deduction, in fact, on the Holmesian method or process, an explanation most flattering to doctors, for it -endos them with penetrating observation and exceptionally fast computer brains. Reretfully this is not-the case. The explanation suggested by Bell, articulatedby Conan Doyle and echoed by Elstein et aL may, on rare occasions, reflect a ipartial truth'2, but is manifestly woefully inadequate. The proferred elaborated explications, the descriptions of the steps by which the 'amazing deductions' are reached, are no more than confabulations covering gaps due not to impairment of memory, but ignorance of the true processes at work. The clinical situation Much has been written lately about the clinical encounter, clinical thinking, decision and diagnosis, and medical practice. In a wide field, this paper is narrowly restricted only to one aspect, the process of diagnosis. The context in which this takes place will therefore be only briefly glimpsed at, as necessary. The medical consultation is, first and foremost, a social encounter. The patient has come to seek help, advice or reassurance: his/her request is couched in
0141-0768/92
060342-04/$02.00/0 © 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 June 1992
the social and cultural terms of his/her group. These include, as in every similar encounter, both nonverbal body language, facial expressions, or paralingual accompaniments, and verbal complaints and information. The doctor responds. Healers in some cultures declare their diagnoses on sight, in others they ask questions. Having learned about the patient and her complaints, many, incluing last century Western doctors, pronounced their diagnosis, without or only after a minimal physical examination. By contrast, modern biomedicine insists on an extensive physical examination supported by laboratory and imaging investigations. Yet, if we accept research findingse, healers and doctors routinely reach a diagnosis, or 'tentative diagnosis', long before these, late, stages of the consultation. Indeed, they do so often even before verbal communication has advanced much beyond hearing the main complaint. Decisions made in the first few seconds Diagnosis or tentative diagnosis apart, some very important decisions are made almost on seeing the patient. An evaluation of the severity of the patient's disability is arrived at almost instantaneously and 'triage', heavily slanted by the type of practice, is
subconsciously instituted. (a) Moreso in singleton, especially rural practices the decision is rapidly made whether the patient is to be treated in the office or sent directly to hospital. (b) The extent of clinical attention required is decided, ie whether the patient is to be fully investigated or only the presenting disability explored. (c) An impression whether the patient's complaints are due to an inorganic disease or 'behavioural disorder' (ie, a predominantly social or emotional condition) is, subconsciously, quickly acquired. In addition the manner in which the patient is to be approached is influenced by an equally instantaneous evaluation of her character and likely responses. Social encounters in medical practice There is little conventional 'social' content-in medical emergency encounters. The patient is often unable to speak or the doctor too occupied. It is -in such situations that a modern doctor follows his intuition very much like many healers in other cultures. The instantaneous diagnosis of an epileptic seizure, or a coma reeking with acetone, are extreme examples. Many fractures simple or compound, once seen, also require only a brief glimpse to diagnose. The same is true of many dermatological conditions, or musculoskeletal deformities. A doctor usually spot-diagnoses these conditions: subsequent 'investigations', no longer aimed at diagnosis, mostly serve to monitor treatment. Though brief and, until the patient is comfortable, often very poor in verbal interchange, these are social encounters. They closely parallel others, in other areas of behaviour, when evaluation is also -instantaneous and as quickly acted upon. This is so when a woman spots another, whom she has no wish to meet, some distance away: when a boy recognizes a football-hero outside a restaurant: when a man, in an 'adventurous' mood, notices a prostitute across the street. Recognition, evaluation, decision and appropriate action are immediate -just as are
the processes concerned with the urgency, venue, management and diagnosis of emergency patients. All these instances share another quality. For it seems, in every case that the whole situation is appreciated simultaneously. There is no suggestion of seeing one thing, then another, no hint of scanning a search for information, or subsequent solution of a jig-saw puzzle. There is a nearly complete absence of language or the concatenating of elements, common to verbal structure and the searching hand. It is as if the left-cerebral-hemisphere is not involved - as if all is achieved by the right cerebrum with its strucural 'geometric' vision, its holistic gestalt view. This receives considerable support from ethological studies: for placed in similar circumstances, in brief encounters, a wide range of animals generally behave not very differently than human beings. They seem to assess their antagonist in the context of the situation, come to appropriate decisions and act upon them. This is true not only of competing male chimpanzees but of ungulates, like Rocky Mountain sheep or even birds and lowlier vertebrates. The cerebral hemispheres ofthese animals, and this is the point, are functionally similar to the nonverbal human right hemisphere. Some animals, like lizards or fish, moreover-possess a much simpler nervous system, no neoencephalon and no cerebral hemispheres.
Checking first impressions Unless decision on encounter precludes it, social interchange, beyond the first few seconds of contact, almost always involves checking of first impressions. These gestalt general impressions seem to evaluate the situation, reveal its structural character not focusing on detail. Sensitive to movement, they instantly warn of change: alerting against danger, spotting opportunities. Above all, at the social encounter, they allow communication: for they are exquisitely sensitive to the changing tonality of musculature, differences in the configuration ofbody or limbs and, especially in Man (as well as other primates and carnivores) that of the facial muscles of expression. They do not, however, so rapidly detect the details which Sherlock Holmes was putatively so good at spotting: this is done by scanning checks, initiated by the left hemisphere. Not conscious or aware of the first, the investigator's explanations naturally rest on the second - on unconscious confabulations!! Checking is extremely important, for however revealing of many aspects of the situation, first impressions can be notoriously misleading. Whenever time allows no final decision is made unless they are, reflexly, tested and verified. In Man this is often achieved by questioning, cross examination or even, more so in police, detective, investigation, by constant prying and parrying. Yet, like all social activities, the process is carried out through both verbal and nonverbal interchanges - indeed, it is primarily associated with the latter. For the nonverbal elements not only emphasize its purpose or enhance its effect, they often determine its character, attimes completely dominate it. They are, of course, the only ones animals use, often spectacularly, as in social competition, combat or courting. Clinically, at the medical interview, checking is accomplished by the process of taking the patient'a medical history. The questions then asked explore a wide variety of activities and events, and when indicated, a wider range of emotions.
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Obtaining the medical history achieves several ends. Reviewing the patient's complaints may allow the doctor to penetrate the patient's presentation of illness (see below), discover to what extent it reflects reality and establish a more objective basis of diagnosis. It sharpens evaluation of the patient's character and its influence on reaction to disability, including factors which may have distorted clinical manifestations or obscured diagnosis. Concurrently response to future therapy may be guessed with greater accuracy. Finally it may permit an orderly review of the circumstances and factors which have played a part in the aetiology and course of the patient's ill health. Viewed in the context of this paper, structural and gestalt processes seem to dominate most aspects of the process of checking, apart from the last which is largely influenced by methodological scrutiny, attempts at concatenation of cause and effect and analytic deduction. The latter attains its apogee in the next phase, now an integral part of the medical interview. Introduced into Western medicine only in the last few centuries, physical examination, beyond feeling the pulse, inspecting the tongue or perfunctory uroscopy, has not become general until this century. A revolutionary step it is, from a structural point of view, when doctors turn to check tentative diagnoses by examination, the end of social interchange: for, by this action, patients are changed from participants in interviews into objects, biological bodies, to be investigated. These can then be prodded, inspected, auscultated and further scrutinized by technological sensors. Methodically gone over, sequentially scanned, patients become part of the evidence - their doctors detectives. The manifestation of disease and its limitations Physical examination and its technological extensions has probably achieved its prominence because of its effectiveness in detecting, and diagnosing, morbid conditions, many of which can be fatal, long before patients are aware of them. This sensitivity has been greatly enhanced by modern medical technology many of the procedures of which have now become routine periodic medical survey measures. Parallels to concurrent assistance detectives have gained from scientific forensic examinations is only too obvious. Silent disease, of the type just considered, is asymptomatic, unfelt, it is not, cannot be, expressed as illness. It is, in effect, a new genre of ill health. It owes its recognition to the changed attitudes which have allowed doctors to examine patients physically and subject them to intensive exploration. Cancer of the cervix, for example, was, until a couple of centuries ago, only diagnosed when vaginal bleeding, especially after coitus, and a malodorous putrid discharge were reported. An earlier diagnosis was made possible by 'the touch' and more so by using the vaginal speculum, as a diagnostic tool (R6camier 1801). Present day technology, cervical cytosmear and colposcopy, have now made very early silent manifestation of this morbid entity easily diagnosable. Physical examination and its associated investigations is essential in the diagnosis of asymptomatic early disease. It is also most effective in the diagnosis of many ambivalent, indeterminate internal diseases. Though these are in many respects 'silent', they are not asymptomatic. Accompanied by a multitude of aches and pains, malaise, nausea or dizziness, their
discomforts are further modified, aggravated by stress or muted by protective mechanisms. These general symptoms are not diagnostically informative and give no hint of the variety of aetiological agents responsible. In contrast to 'external', musculo-skeletal or dermatological conditions, often diagnosed on sight, these 'internal' diseases are indistinct and consequently liable to be missed or ignored by healer and doctor. Their symptoms are therefore, subconsciously, often exaggerated by the patient visiting the doctor to ask for help. Others, per contra, find it relatively easy to suppress the symptoms of these diseases until forced to admit ill health, when a deteriorating condition can no longer be concealed. Despite their confusing superficially similar symptomatology the diagnosis of these 'indefinite' internal diseases, when assisted by modern investigatory methods, is in many cases not too difficult. In others it is both complicated and not without risk and frustration. This is because many symptoms associated with them are also utilized by a variety of behavioural disorders. The sharing of these 'expressions of discomfort' is not, as in malingering, an act of conscious deceit. It is a basic biological-ethological trait common to Man and animal. Symptoms like fatigue, listlessness, a stooping-crouching pose or a tendency to shun company are, for instance, as much part of the expressions of defeat, of anxiety or depression as they are manifestations of organic ill health, like anaemia, cancer or myxoedema. The diagnostic problems this situation has given rise to have never been satisfactorily solved. The absence of positive, mensural, findings has made their diagnosis, according to biomedicine, possible only by exclusion. The risk of missing a potentially fatal condition has, furthermore, been regarded as mandating a thorough, extensive, diagnostic investigation. Logically this search can end only when positive findings are discovered - yet this is an a priori impossibility in behavioural disorders. Differentiating between appearances and reality, masquerade and actuality, the recognition of bluff, the penetration of outward expression, of the concealment of a poker-face are social skills possessed to a varying degree by everybody. In large part innate, their culti'vation growth and effective practice are essential to anyone who is to make her way in society including, incidentally, animal societies. Meeting patients, a doctor spontaneously, 'instinctively', takes their measure and, with the help ofthese social skills, is instantaneously aware whether the person facing him/her is most likely affected by a physical, organic disease or is, in all probability, subject to a behavioural disorder. Diagnosis and subsequent management vary greatly. Wiser, older, practitioners follow these first impressions and, having excluded the more serious organic disorders by one or two general tests, concentrate on the patient rather than the presenting complaint. They know the damage zealous investigations can do when they 'fix the arrow of hypochondria, it may be for life"4 in patients who are already 'off-balance'. Tacitly theirs is a primary diagnosis of a behavioural disorder.
The presentation of illness The attitude displayed when coming to seek help, relief from pain, healing of disability or even
Journal of the Royal Society of Medicine Volume 85 June 1992
treatment of a passing ailment is the first image of the patient to impress the doctor. It is bound to colour his/her view of the patient and strongly influence diagnosis. Emergency situations apart, a man or woman visits the doctor only after a relatively prolonged period of doubt, denial, debate and delay. The first hints are often ignored, later it is generally hoped all discomfort will 'just go away': the advice of friends or family is eventually solicited, some even turn to popular do-ityourself medical books, before fixing an appointment with the doctor. Memories of sick acquaintances, the opinions of those who are trusted and the behaviour of others who were subject to similar complaints, then all combine in forming both 'diagnosis' and image of the increasingly accepted illness. This image is not, structurally, socially or historically, especially aimed at the doctor. It is presented to family and friends, held to the view of all, as are other afflictions, like death, helplessness and, in some cultures, deformity and poverty. The presentation of illness seldom employs histrionically strong terms such as exhibited in mourning, lamentation or display of disaster. In fact, in some societies, where the range of medical disorders is culturally limited, expressions of illness are few though often better defined. In these circumstances it is easy for healers to diagnose a disability on sight. Despite their ethnically confusing variety, even the toned-down displays in our contemporary culture cannot fail but assist the Western doctor - for they inform of, or hint at, the diagnosis which the patient suspects and so may not only offer clues but allow the doctor better to direct reassurance and, often, treatment.
Diagnosis While the manner by which diagnosis is reached has been discussed, the context in which this is achieved has not been examined. Doctors and blacktrackers However approached, medical diagnosis differs both in contents and circumstances from either scientific research or detective search. Scientists and detectives, each in their own way, attempt to identify unknown agents, material entities or active forces, which have caused a change or a physical condition which they can thoroughly investigate. A doctor is, however, usually familiar with the various possible disease entities likely to affect the patient. He is also, often, not a stranger to the latter, especially in rural and singleton practice or, as in Britain, in 'closed' practice. His/her task is, in fact, to decide which one, of a short list of disorders, is affecting Mr Brown or Mrs Green whom he knows and with whose reactions he may be very familiar. Far from following the example of Sherlock Holmes and minutely examine the patient with a magnifying glass, the doctor can, like a blacktracker identifying spoor left by a familiar animnal, almost instantly recognize the effects of 'thie bulg that's goin' around' or a resurgence of a mood, a behavioural disorder. Uncommon conditions may take a little longer, but seldom more than a minute. Occasionally he/she is unable to place the condition and be forced to relyF on
methods of detection which employ tests usually utilized for the checking of first impressions, indeed follow the protocol of investigation laid down in medical texts, play the role ofthe doctor-scientist. At times the doctor turns to consultants, possessing special experience and more sophisticated technological sensors, in order to sharpen a diagnosis, seldom to determine it. Rarely, as recently in the case of AIDS, even they are stumped - and the experimental scientists have to be summoned. Conclusion The role of the doctor-scientist has been prompted by medical educators since Boerhaave of Leiden (1668-1738) and before. Medicine's recent heroic age has witnessed its steady growth. Doctor-scientists have, during the last century and a half, step by step, deciphered human physiology, the nature of endocrine secretions and biochemical reactions, identified the invisible microscopic agents of disease and damage caused by toxins, by excess and by deficiencies, studied pathological and healing processes and the defences of the immunological system and gained insight into the workings of the nervous system and, to a lesser degree, of its higher functions. Their achievements have encouraged the role of science in medicine. Scientific education was advanced by the Flexner report in North America and parallel developments in Western Europe and has since resulted in an unprecedented, accelerated expansion of medicine, or, more accurately, biomedicine, and scientific medical research. Unfortunately these developments have been literally one sided, with the left side of the brain not caring, disregarding, even despising, what the right can and does offer. Medical practice, however, can not but continue as a social institution, dependent on social skills. Yet, when examined 'scientifically' analyses have repeatedly been hampered by bias. The fiction of Sherlock Holmes2 continues to be regarded as a suitable paradigm for the diagnostic process'. Even when a multi-levelled approach is put forward as a more realistic model2, the role of the older parts of the brain, the legacy of animal forebearers, of socialized primates, of hunters and blacktrackers, is still not recognized. Consciousness of these elements in the understanding of our ills, is innately, physiologically, suppressed. It is elided, deleted from the left hemispheric language of awareness, erased from all records, obliterated from medicine's repeated endeavours at a holistic, comprehensive perception of disease, of illness and of diagnosis. References 1 Peschel RE, Peschel E. What physicians have in common with -Sherlock Holmes: discussion paper. J R Soc Med
1989;82:33-6 2 Oderwald AK, Sebus JH. The physician and Sherlock Holmes. J R Soc Med 1991;84:151-2 3 Elstein AS, Shulman LS, Sprafka SA. Medical problem solving. An analysis of linical reasoning. Boston: Harvard
Uniiversity Press,
1978
4 Allbutt TO. The neuroses of tAhe viscera. Lancet 1884; i:459-63 (Accepted 11- September 1991)
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Journal of the Royal Society of Medicine Volume 85 June 1992
The Sherlock Holmes paradigm detectives and diagnosis: discussion paper
Joel Wilbush DPhil FRCOG
Department of Anthropology, University of Alberta, Edmonton, AB Canada;
Keywords: Sherlock Holmes; medical encounter; social evaluation; diagnosis; behavioural disorders
Introduction Many of the factors which have contributed to the immense popularity of the detective novel, and Sherlock Holmes, paradoxically remin 'an unsolved mystery'. Interpretations abound, but none fully accounts for the undiminished enthusiasm of so many for this genre of literature, nor for the recurrent impact of Sherlock Holmes. The master-detective is especially associated 'with the medical world, (for) three physicians - two real and one fictional - actually help shape and define him'". The readers' friend, the fictional Dr Watson is, at best, but a literary device. Dr Conan Doyle is more author than physician, and often, as students of Holmesiasia attest, a careless one. He is also guilty, as a recent paper2 points out, of distortion of reality: for no solution of a complex murder or clinical case is accomplished pursuing a unilineal course. Investigations follow different levels of enquiry: some succeed, others not, many clues leading nowhere. Only an author can lead the hero to the right clues in the right order -for he alone has glimpsed the picture of the completed jig-saw puzzle2. Dr Joseph Bell, whose clinical approach has served as a model for the Holmesian method, is the most interesting -and the least understood. This is not surprising, for even Dr Bell himself did not really comprehend the processes by which he reached his conclusions. Doctors and detectives The detective novel deals with murder, one of the oldest themes to concern mankind. Concurrently it glorifies the most recent of humanity's advances, modern science. Thus viewed, it paraphrases in modern terms the eternal theme ofthe struggle between good and evil, between ratiocination and ignorance, left-cerebral-hemisphere logic and subcortical, even right-cerebral, impulsive behaviour. It is the power of science to deduce who is the killer, identify the pathogen, which has attracted doctors, who feel a kinship with the rationalistic heroes of the detective novel. Diagnosis, as many students are often told, is exciting, like the action in a detective novel. It is this fascination with the power of science which has allowed not only the 'forgetting the distinction between (fiction) and reality', 'coincidence' or 'many levels and open ends' of diagnostic investigation2, but worst of all, the clinical situation. Though regularly concerned with the emotional or other accounts of witnesses, the focus of detective investigation are the physical remains, the clues to the crime. The clinical encounter, on the other hand, centres on the patient, and however wide it ranges it must return to the patient and her treatment. Detectives are engaged in objective exploration:
doctors, even specialized biomedical operators, are participating in a social process.
Medical problem solving Dr Bell's demonstrations of the;power of observation and deduction to establish many of the non-medical aspects of patients' lives were unusual but,-obviously, both enttaining and effective in impresing studets with the importance of attention to detail. A much more widespread histrionic prop, routinely employed by many more medical teachers and practitioners, is spot-diagnosis. This allows not only oneupmanship, but also adds interest to subsequent explanation of the proces by which it was putatively reached. Today, however, it is frowned upos; probably not so much because not too rarely it proves iaccurate, but mostly because of a feeling that it does not satisfy scientific standards of diagnoais.Yet, research in medial p Qblem solving has shown that not only 'spot' but most clinical diagnoses are 'instantaneous'. Surpingly, it has also demonstrated that the difference between expernenced physicians and relative beginners is, alost isignificant. The average physician reaches a diagnosis in approximately 30 seconds, an expert takes, less, but even a comparatively recent graduate can make it in under one minute3. The epitemological interpretation proposed by this research disappointingly does not greatly differ from that offered by Dr Bell over a century ago. It rests on ripid -observation and deduction, in fact, on the Holmesian method or process, an explanation most flattering to doctors, for it -endos them with penetrating observation and exceptionally fast computer brains. Reretfully this is not-the case. The explanation suggested by Bell, articulatedby Conan Doyle and echoed by Elstein et aL may, on rare occasions, reflect a ipartial truth'2, but is manifestly woefully inadequate. The proferred elaborated explications, the descriptions of the steps by which the 'amazing deductions' are reached, are no more than confabulations covering gaps due not to impairment of memory, but ignorance of the true processes at work. The clinical situation Much has been written lately about the clinical encounter, clinical thinking, decision and diagnosis, and medical practice. In a wide field, this paper is narrowly restricted only to one aspect, the process of diagnosis. The context in which this takes place will therefore be only briefly glimpsed at, as necessary. The medical consultation is, first and foremost, a social encounter. The patient has come to seek help, advice or reassurance: his/her request is couched in
0141-0768/92
060342-04/$02.00/0 © 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 June 1992
the social and cultural terms of his/her group. These include, as in every similar encounter, both nonverbal body language, facial expressions, or paralingual accompaniments, and verbal complaints and information. The doctor responds. Healers in some cultures declare their diagnoses on sight, in others they ask questions. Having learned about the patient and her complaints, many, incluing last century Western doctors, pronounced their diagnosis, without or only after a minimal physical examination. By contrast, modern biomedicine insists on an extensive physical examination supported by laboratory and imaging investigations. Yet, if we accept research findingse, healers and doctors routinely reach a diagnosis, or 'tentative diagnosis', long before these, late, stages of the consultation. Indeed, they do so often even before verbal communication has advanced much beyond hearing the main complaint. Decisions made in the first few seconds Diagnosis or tentative diagnosis apart, some very important decisions are made almost on seeing the patient. An evaluation of the severity of the patient's disability is arrived at almost instantaneously and 'triage', heavily slanted by the type of practice, is
subconsciously instituted. (a) Moreso in singleton, especially rural practices the decision is rapidly made whether the patient is to be treated in the office or sent directly to hospital. (b) The extent of clinical attention required is decided, ie whether the patient is to be fully investigated or only the presenting disability explored. (c) An impression whether the patient's complaints are due to an inorganic disease or 'behavioural disorder' (ie, a predominantly social or emotional condition) is, subconsciously, quickly acquired. In addition the manner in which the patient is to be approached is influenced by an equally instantaneous evaluation of her character and likely responses. Social encounters in medical practice There is little conventional 'social' content-in medical emergency encounters. The patient is often unable to speak or the doctor too occupied. It is -in such situations that a modern doctor follows his intuition very much like many healers in other cultures. The instantaneous diagnosis of an epileptic seizure, or a coma reeking with acetone, are extreme examples. Many fractures simple or compound, once seen, also require only a brief glimpse to diagnose. The same is true of many dermatological conditions, or musculoskeletal deformities. A doctor usually spot-diagnoses these conditions: subsequent 'investigations', no longer aimed at diagnosis, mostly serve to monitor treatment. Though brief and, until the patient is comfortable, often very poor in verbal interchange, these are social encounters. They closely parallel others, in other areas of behaviour, when evaluation is also -instantaneous and as quickly acted upon. This is so when a woman spots another, whom she has no wish to meet, some distance away: when a boy recognizes a football-hero outside a restaurant: when a man, in an 'adventurous' mood, notices a prostitute across the street. Recognition, evaluation, decision and appropriate action are immediate -just as are
the processes concerned with the urgency, venue, management and diagnosis of emergency patients. All these instances share another quality. For it seems, in every case that the whole situation is appreciated simultaneously. There is no suggestion of seeing one thing, then another, no hint of scanning a search for information, or subsequent solution of a jig-saw puzzle. There is a nearly complete absence of language or the concatenating of elements, common to verbal structure and the searching hand. It is as if the left-cerebral-hemisphere is not involved - as if all is achieved by the right cerebrum with its strucural 'geometric' vision, its holistic gestalt view. This receives considerable support from ethological studies: for placed in similar circumstances, in brief encounters, a wide range of animals generally behave not very differently than human beings. They seem to assess their antagonist in the context of the situation, come to appropriate decisions and act upon them. This is true not only of competing male chimpanzees but of ungulates, like Rocky Mountain sheep or even birds and lowlier vertebrates. The cerebral hemispheres ofthese animals, and this is the point, are functionally similar to the nonverbal human right hemisphere. Some animals, like lizards or fish, moreover-possess a much simpler nervous system, no neoencephalon and no cerebral hemispheres.
Checking first impressions Unless decision on encounter precludes it, social interchange, beyond the first few seconds of contact, almost always involves checking of first impressions. These gestalt general impressions seem to evaluate the situation, reveal its structural character not focusing on detail. Sensitive to movement, they instantly warn of change: alerting against danger, spotting opportunities. Above all, at the social encounter, they allow communication: for they are exquisitely sensitive to the changing tonality of musculature, differences in the configuration ofbody or limbs and, especially in Man (as well as other primates and carnivores) that of the facial muscles of expression. They do not, however, so rapidly detect the details which Sherlock Holmes was putatively so good at spotting: this is done by scanning checks, initiated by the left hemisphere. Not conscious or aware of the first, the investigator's explanations naturally rest on the second - on unconscious confabulations!! Checking is extremely important, for however revealing of many aspects of the situation, first impressions can be notoriously misleading. Whenever time allows no final decision is made unless they are, reflexly, tested and verified. In Man this is often achieved by questioning, cross examination or even, more so in police, detective, investigation, by constant prying and parrying. Yet, like all social activities, the process is carried out through both verbal and nonverbal interchanges - indeed, it is primarily associated with the latter. For the nonverbal elements not only emphasize its purpose or enhance its effect, they often determine its character, attimes completely dominate it. They are, of course, the only ones animals use, often spectacularly, as in social competition, combat or courting. Clinically, at the medical interview, checking is accomplished by the process of taking the patient'a medical history. The questions then asked explore a wide variety of activities and events, and when indicated, a wider range of emotions.
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Obtaining the medical history achieves several ends. Reviewing the patient's complaints may allow the doctor to penetrate the patient's presentation of illness (see below), discover to what extent it reflects reality and establish a more objective basis of diagnosis. It sharpens evaluation of the patient's character and its influence on reaction to disability, including factors which may have distorted clinical manifestations or obscured diagnosis. Concurrently response to future therapy may be guessed with greater accuracy. Finally it may permit an orderly review of the circumstances and factors which have played a part in the aetiology and course of the patient's ill health. Viewed in the context of this paper, structural and gestalt processes seem to dominate most aspects of the process of checking, apart from the last which is largely influenced by methodological scrutiny, attempts at concatenation of cause and effect and analytic deduction. The latter attains its apogee in the next phase, now an integral part of the medical interview. Introduced into Western medicine only in the last few centuries, physical examination, beyond feeling the pulse, inspecting the tongue or perfunctory uroscopy, has not become general until this century. A revolutionary step it is, from a structural point of view, when doctors turn to check tentative diagnoses by examination, the end of social interchange: for, by this action, patients are changed from participants in interviews into objects, biological bodies, to be investigated. These can then be prodded, inspected, auscultated and further scrutinized by technological sensors. Methodically gone over, sequentially scanned, patients become part of the evidence - their doctors detectives. The manifestation of disease and its limitations Physical examination and its technological extensions has probably achieved its prominence because of its effectiveness in detecting, and diagnosing, morbid conditions, many of which can be fatal, long before patients are aware of them. This sensitivity has been greatly enhanced by modern medical technology many of the procedures of which have now become routine periodic medical survey measures. Parallels to concurrent assistance detectives have gained from scientific forensic examinations is only too obvious. Silent disease, of the type just considered, is asymptomatic, unfelt, it is not, cannot be, expressed as illness. It is, in effect, a new genre of ill health. It owes its recognition to the changed attitudes which have allowed doctors to examine patients physically and subject them to intensive exploration. Cancer of the cervix, for example, was, until a couple of centuries ago, only diagnosed when vaginal bleeding, especially after coitus, and a malodorous putrid discharge were reported. An earlier diagnosis was made possible by 'the touch' and more so by using the vaginal speculum, as a diagnostic tool (R6camier 1801). Present day technology, cervical cytosmear and colposcopy, have now made very early silent manifestation of this morbid entity easily diagnosable. Physical examination and its associated investigations is essential in the diagnosis of asymptomatic early disease. It is also most effective in the diagnosis of many ambivalent, indeterminate internal diseases. Though these are in many respects 'silent', they are not asymptomatic. Accompanied by a multitude of aches and pains, malaise, nausea or dizziness, their
discomforts are further modified, aggravated by stress or muted by protective mechanisms. These general symptoms are not diagnostically informative and give no hint of the variety of aetiological agents responsible. In contrast to 'external', musculo-skeletal or dermatological conditions, often diagnosed on sight, these 'internal' diseases are indistinct and consequently liable to be missed or ignored by healer and doctor. Their symptoms are therefore, subconsciously, often exaggerated by the patient visiting the doctor to ask for help. Others, per contra, find it relatively easy to suppress the symptoms of these diseases until forced to admit ill health, when a deteriorating condition can no longer be concealed. Despite their confusing superficially similar symptomatology the diagnosis of these 'indefinite' internal diseases, when assisted by modern investigatory methods, is in many cases not too difficult. In others it is both complicated and not without risk and frustration. This is because many symptoms associated with them are also utilized by a variety of behavioural disorders. The sharing of these 'expressions of discomfort' is not, as in malingering, an act of conscious deceit. It is a basic biological-ethological trait common to Man and animal. Symptoms like fatigue, listlessness, a stooping-crouching pose or a tendency to shun company are, for instance, as much part of the expressions of defeat, of anxiety or depression as they are manifestations of organic ill health, like anaemia, cancer or myxoedema. The diagnostic problems this situation has given rise to have never been satisfactorily solved. The absence of positive, mensural, findings has made their diagnosis, according to biomedicine, possible only by exclusion. The risk of missing a potentially fatal condition has, furthermore, been regarded as mandating a thorough, extensive, diagnostic investigation. Logically this search can end only when positive findings are discovered - yet this is an a priori impossibility in behavioural disorders. Differentiating between appearances and reality, masquerade and actuality, the recognition of bluff, the penetration of outward expression, of the concealment of a poker-face are social skills possessed to a varying degree by everybody. In large part innate, their culti'vation growth and effective practice are essential to anyone who is to make her way in society including, incidentally, animal societies. Meeting patients, a doctor spontaneously, 'instinctively', takes their measure and, with the help ofthese social skills, is instantaneously aware whether the person facing him/her is most likely affected by a physical, organic disease or is, in all probability, subject to a behavioural disorder. Diagnosis and subsequent management vary greatly. Wiser, older, practitioners follow these first impressions and, having excluded the more serious organic disorders by one or two general tests, concentrate on the patient rather than the presenting complaint. They know the damage zealous investigations can do when they 'fix the arrow of hypochondria, it may be for life"4 in patients who are already 'off-balance'. Tacitly theirs is a primary diagnosis of a behavioural disorder.
The presentation of illness The attitude displayed when coming to seek help, relief from pain, healing of disability or even
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treatment of a passing ailment is the first image of the patient to impress the doctor. It is bound to colour his/her view of the patient and strongly influence diagnosis. Emergency situations apart, a man or woman visits the doctor only after a relatively prolonged period of doubt, denial, debate and delay. The first hints are often ignored, later it is generally hoped all discomfort will 'just go away': the advice of friends or family is eventually solicited, some even turn to popular do-ityourself medical books, before fixing an appointment with the doctor. Memories of sick acquaintances, the opinions of those who are trusted and the behaviour of others who were subject to similar complaints, then all combine in forming both 'diagnosis' and image of the increasingly accepted illness. This image is not, structurally, socially or historically, especially aimed at the doctor. It is presented to family and friends, held to the view of all, as are other afflictions, like death, helplessness and, in some cultures, deformity and poverty. The presentation of illness seldom employs histrionically strong terms such as exhibited in mourning, lamentation or display of disaster. In fact, in some societies, where the range of medical disorders is culturally limited, expressions of illness are few though often better defined. In these circumstances it is easy for healers to diagnose a disability on sight. Despite their ethnically confusing variety, even the toned-down displays in our contemporary culture cannot fail but assist the Western doctor - for they inform of, or hint at, the diagnosis which the patient suspects and so may not only offer clues but allow the doctor better to direct reassurance and, often, treatment.
Diagnosis While the manner by which diagnosis is reached has been discussed, the context in which this is achieved has not been examined. Doctors and blacktrackers However approached, medical diagnosis differs both in contents and circumstances from either scientific research or detective search. Scientists and detectives, each in their own way, attempt to identify unknown agents, material entities or active forces, which have caused a change or a physical condition which they can thoroughly investigate. A doctor is, however, usually familiar with the various possible disease entities likely to affect the patient. He is also, often, not a stranger to the latter, especially in rural and singleton practice or, as in Britain, in 'closed' practice. His/her task is, in fact, to decide which one, of a short list of disorders, is affecting Mr Brown or Mrs Green whom he knows and with whose reactions he may be very familiar. Far from following the example of Sherlock Holmes and minutely examine the patient with a magnifying glass, the doctor can, like a blacktracker identifying spoor left by a familiar animnal, almost instantly recognize the effects of 'thie bulg that's goin' around' or a resurgence of a mood, a behavioural disorder. Uncommon conditions may take a little longer, but seldom more than a minute. Occasionally he/she is unable to place the condition and be forced to relyF on
methods of detection which employ tests usually utilized for the checking of first impressions, indeed follow the protocol of investigation laid down in medical texts, play the role ofthe doctor-scientist. At times the doctor turns to consultants, possessing special experience and more sophisticated technological sensors, in order to sharpen a diagnosis, seldom to determine it. Rarely, as recently in the case of AIDS, even they are stumped - and the experimental scientists have to be summoned. Conclusion The role of the doctor-scientist has been prompted by medical educators since Boerhaave of Leiden (1668-1738) and before. Medicine's recent heroic age has witnessed its steady growth. Doctor-scientists have, during the last century and a half, step by step, deciphered human physiology, the nature of endocrine secretions and biochemical reactions, identified the invisible microscopic agents of disease and damage caused by toxins, by excess and by deficiencies, studied pathological and healing processes and the defences of the immunological system and gained insight into the workings of the nervous system and, to a lesser degree, of its higher functions. Their achievements have encouraged the role of science in medicine. Scientific education was advanced by the Flexner report in North America and parallel developments in Western Europe and has since resulted in an unprecedented, accelerated expansion of medicine, or, more accurately, biomedicine, and scientific medical research. Unfortunately these developments have been literally one sided, with the left side of the brain not caring, disregarding, even despising, what the right can and does offer. Medical practice, however, can not but continue as a social institution, dependent on social skills. Yet, when examined 'scientifically' analyses have repeatedly been hampered by bias. The fiction of Sherlock Holmes2 continues to be regarded as a suitable paradigm for the diagnostic process'. Even when a multi-levelled approach is put forward as a more realistic model2, the role of the older parts of the brain, the legacy of animal forebearers, of socialized primates, of hunters and blacktrackers, is still not recognized. Consciousness of these elements in the understanding of our ills, is innately, physiologically, suppressed. It is elided, deleted from the left hemispheric language of awareness, erased from all records, obliterated from medicine's repeated endeavours at a holistic, comprehensive perception of disease, of illness and of diagnosis. References 1 Peschel RE, Peschel E. What physicians have in common with -Sherlock Holmes: discussion paper. J R Soc Med
1989;82:33-6 2 Oderwald AK, Sebus JH. The physician and Sherlock Holmes. J R Soc Med 1991;84:151-2 3 Elstein AS, Shulman LS, Sprafka SA. Medical problem solving. An analysis of linical reasoning. Boston: Harvard
Uniiversity Press,
1978
4 Allbutt TO. The neuroses of tAhe viscera. Lancet 1884; i:459-63 (Accepted 11- September 1991)
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