Doctor As Detective
Dr Jitendra Ingole
MD Internal Medicine
Associate Professor, SKNMC & GH, Pune
Diagnosis …Art or Science ?
Best answer would be a judicial
combination of both.
History & Clinical examination are
For they provide foundation for planning
out investigations or treatment.
Doctor as detective
White Coats and finger prints
Isn’t much of a doctor’s work alike to that
of a detective?
Routine use of sophisticated diagnostic
tools is killing the art of clinical
Blind faith in technology
Pre determined diagnostic algorithms
How to confront the problems posed
by burgeoning number of available
The need of hour is ……
Harmonic fusion of all investigative
methods of fictional detectives.
Avoid slavish adherence to protocols.
What is happening today is……
Burn money to make diagnostic work
Losing intellectual pleasure that comes
from careful diagnostic reasoning.
An investigation, however sophisticated
and expensive, if performed
inappropriate clinical settings, will be
Some analogies between detective
and clinical methods
Try to restore status quo undermined by
crime or disease
Thrive on climate of faith in capabilities
of science and base their methods on
interpretation of clues and s/s.
Reach final conclusion by decoding
signs and symptoms often meaning
less to layman.
What Sherlock Holmes said……..
Qualities Of Ideal Detective
Qualities of Ideal Detective…..
Shared qualities of detectives &
Ability in Observation
Ability in Deduction
Ability to reconstruct psychological &
Ability to spot inconsistencies
Observation & reasoning…..
General to particular
Particular to general
Forming an explanatory
Not only presence of evidence but also their absence is important.
So, here is the flaw…..
Flawed belief that disease can be
diagnosed accurately from its specific
And Lo Behold……
We are taught similar way from UG
days…. Only to learn hard fact later,
that signs/symptoms may not follow
Overcoming the blind faith is very
Mental Archive of Past cases
There comes a time, when for every
addition, there is deletion of previous
knowledge from our memory.
It is important to know what is important
& what’s not.
And do not allow useless to replace
I have internet connection……hence
I am invincible doctor….because I
have every possible answer in the
The Armchair Specialist…?
Having access to knowledge does not
mean that it will be utilised accurately.
Net searches are worth if & only if
clinician conserves his bedside role.
Reconstruct Psychological Profile
“ Are you investigating murderer (Disease)
or Victim (Patient). ”
A detective says ……
“ I will identify murderer when I fully know
A doctor says …..
“ I will identify the disease when I fully
know patient. ”
Ability to Recognise Inconsistencies
Normal or low voltage ECG, HOCM
Sherlock Holmes Aphorisms……
You see but you do not observe.
My method is founded upon observation of trifles.
Never trust general impressions, but concentrate on
It is capital mistake to theorise before one has the data.
Sherlock Holmes Aphorisms……
There is nothing like first hand evidence.
There is nothing more deceptive than an obvious fact.
The world is full of obvious things which nobody by any
When you have eliminated all impossible, whatever
remain, however improbable, must be the truth.
And the punch line is …….
Do not try to twist the facts to suit theories. Rather,
theories should suit the facts.
Adherence to protocols and
Though guidelines raise average quality
of care, but if applied uncritically and
blindly, can cause pitfalls.
Thus the need of hour is…….
Proper and Juridical use of clinical or
Take Home Message is …….
Clinical method as science and art
Spot inconsistencies among clinical ,
instrumental and lab exam
Consider not only what is present but also
what is missing.
Capacity to establish links – physical lab.,
Simple logical clinical exam has same
value as complex expensive investigation.
Doctors, Detectives and
How detective like approach can help to doctors to make
The lady detective….Mma Ramotswe
Waiting to see doctor for about an hour
outside his consulting room
Makes accurate & intelligent
observations…which then she narrates
First patient was butcher……
Lost a finger on his left hand
Scratching his body
Second female patient unable to
sleep at night…… How ?
Slept off while waiting
Had to be awakened on her turn
Milk stains on her clothes… must have
been awake due to baby
Third female patient….Unhappy
Unhappy but not depressed……
Because she was continuously knitting
and was busy which a depressed
person can not do.
And then, her doctor tells detective not
to eat too much doughnuts…….How ?
Because her weight not decreasing
since last few years.
Sugar in front of her dress which was
spilled from doughnuts.
The Message is clear…….
In other words, history taking and
clinical examination should not become
too structured ritual.
Think And Act……
It also means to have a clear
systematic approach in mind whether
taking history or doing clinical