Technology makes observed diagnosis obsolete

Key Points

Later in life, I learned that Sherlock Holmes resembled a great medical diagnostician for good reason. Joseph Bell lectured at the University of Edinburgh. He routinely amazed both patients and medical students by picking a stranger out of a crowd or a patient in an examining room and deducing occupation, recent activities, medical complaints, and even medical diagnoses. He then would explain what observations he had made that allowed him to draw his conclusions. The name of one of Bell's medical students, Arthur Conan Doyle, lives on today because of the literary character Bell inspired.

As everyone knows, ophthalmologists are among the most intelligent of physicians (not just the best looking). As exemplified by Conan Doyle and Robin Cook, they are often good writers, as well (you'd never deduce that fact, of course, from reading these editorials). Ironically, as an ophthalmologist, Conan Doyle was a total failure. He trained in Vienna (the training was only 1 year in those days), returning to London in 1891 to set up his practice. He had so few patients that he had plenty of time for writing, and he reported such a low income from his practice that the English tax authorities suspected him of tax evasion. Wisely, he decided to concentrate on writing.

If you watch crime shows, you know that observation and deduction by detectives is being replaced by forensic testing and DNA matching. Even the accounts of eye witnesses, we learn, are notoriously unreliable.

My sense with physicians today is that technology similarly is replacing observation, history-taking, and careful deduction. Internists tell me that skill with a stethoscope is now less important in the day of echocardiograms and spiral computed tomography scans. We monitor glaucoma progression with automated perimetry and nerve fiber layer analysis. It used to be that only retinal specialists could discern and correctly interpret subtle macular pathologies such as early cyst formation, but now optical coherence tomography renders the pathology obvious.

It used to be that my clinic would include occasional patients who had seen one or two neuro-ophthalmologists trying to find the cause of "unexplained visual loss." The residents and fellows would be impressed when we solved the mystery by diagnosing mild keratoconus. Now, with the ubiquity of topography devices in comprehensive ophthalmologists' offices, our services rarely are needed to establish this diagnosis.

Certainly the technology that gives us these objective and quantifiable measures of the eye's anatomy is good. On the other hand, it would be a shame if we allowed our observational and history-taking skills to atrophy. Maybe I'm the only one, but I like reading Sherlock Holmes stories more than watching "CSI."

References

• Lycett A. The man who created Sherlock Holmes. New York, NY: Free Press; 2007.

• http://en.wikipedia.org/wiki/Joseph_Bell/