PERIPHERALIA

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In years gone by, the diagnostic process was an intellectual 
exercise in history taking and examination, then choosing 
the appropriate investigation. In the Medieval Ages, when 
I started practising, we performed X-rays and a few blood 
tests, and had a centrifuge and microscope in the consulting 
rooms. There were no ultrasounds or scans, and I was mostly 
confident of my assessments based on the history and 
examination.

Now, I have a great array of pads on my desk for radiologists, 
ultrasounds, densitometry and scans, as well as large sheets 
for blood tests, containing little boxes, eagerly waiting to be 
ticked.

In the past, a patient who complained of tiredness would 
be questioned and examined to exclude anaemia and 
hypothyroidism, and if nothing was found the patient would 
be quietly reassured. Sometimes, the age-old ritual of a 
bottle of tonic was prescribed.

Nowadays, I tick the boxes for the full blood count, iron levels 
and thyroid functions with a purposeful flourish of the pen. It 
is partly a confirmatory investigation, although it also morphs 
into other background motives, such as the reassurance 
investigation and the anti-litigation investigation. There is 
always the fear of missing a diagnosis to the detriment of the 
patient’s health, but also to the detriment of one’s reputation, 
and then the final all-pervading fear of litigation. It is for this 
reason that I do not read Casebook, the journal of the Medical 
Protection Society, at night. One should not read scary stories 
before going to sleep.

Lastly, there is the concept of the therapeutic investigation. 
The effect of a normal X-ray, normal scan, ECG or blood tests 
is reassuring, both to the doctor and the patient. I find that 
even a positive result indicating a pathological process may 
be therapeutic, especially in treatable conditions, in that the 
patient then has an explanation for his or her symptoms, and 
there is the relief that “it’s not all in my mind, doctor”.

Nevertheless, there are many “down” sides to these 
investigations, including false negatives and false positives, 
as well as the finding of incidentalomas. These engender 
further investigations and side-effects, as described in the 
Ulysses syndrome, which is the long, complicated journey of 
investigations following a false positive result. This is like the 

proverbial blind man who is searching in a dark cellar for a 
black cat that isn’t there.

There is also the result, which is one decimal point over or 
under the normal limit, with a large bold “L” for “Low”, or 
“H” for “High”, beside it, involving me having to perform 
considerable back-peddaling.  

So what is an unnecessary investigation? One school of 
thought is for only conducting those investigations which 
are appropriate to the suspected condition. This is the 
intellectually and economically correct approach. The 
“umbrella” or “blunderbuss” approach of conducting a whole 
gamut of blood tests and scans to cover every possible 
eventuality has evolved because the boxes are there to 
be ticked nowadays, as well as all of the above reasons of 
reassurance and fear of legal consequences. 

There are two other arguments for performing investigations 
which may not be particularly diagnostically relevant.  The 
first is to establish baselines for comparison at a further stage 
in the illness or in the patient’s life, provided that these are 
not repeated by different doctors and specialists, who are 
not communicating with one another.  

The second argument is to ensure patient satisfaction, 
engendered by increasing public knowledge and the 
demand for modern technology. This belief that technology 
can solve all of our problems has been called “silicon faith”. In 
the public mind, if a scan or imaging has not been carried out, 
there is lingering dissatisfaction, confirmed by neighbours 
and the tellers at Spar who have extensive knowledge on 
these matters. The scanner has now become the final arbiter 
of life on this earth.

Therefore, I am considering replacing the door of my 
consultation room with a whole body scanner. Patients may 
come and stand in front of the door and press a button, upon 
which their whole body will be scanned. A printout with the 
results will then come out of the wall on the left hand side of 
the door. I will install an ATM on the other side for them to 
pay the account.   

I will be on the golf course.  

Chris Ellis, Family Physician, Pietermaritzburg, KwaZulu-Natal 
e-mail: cristobalellis@gmail.com

The therapeutic investigation