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Digging holes and weaving tapestries: two approaches to the clinical encounter
  1. John Launer
  1. Associate Editor, Postgraduate Medical Journal, London, UK
  1. Correspondence to Dr John Launer, London, UK; johnlauner{at}

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Much of medicine consists of getting to the bottom of things. Here is a typical example. A man in his sixties walks into an emergency department complaining of brief loss of consciousness (myself, as it happens, exactly 3 years ago). Within a few minutes, the emergency medicine consultant gets to the bottom of things: an ECG shows complete heart block and so a few days later the patient is fitted with a pacemaker. There are of course further questions to be explored, such as what the underlying pathology was (ischaemic heart disease) and what the antecedents were (a strong family history.) One can even dig further down, discovering more at each level (like lipid disorders and genes). Each of these is a distinct thing, and each has a bottom. It is a very rewarding activity, and one that scientific medicine, and investigative medicine in particular, are especially good at.

Sometimes, however, people come to see us with problems that do not seem either to be things or to have bottoms. Every doctor is familiar with patients who present with a vague and variable combination of fatigue, weakness, headaches, palpitations, muscular aches, abdominal pains, backache and light-headedness. Usually, we feel obliged to dig down below each of these symptoms in a conventional medical way, knowing the whole time that we are most unlikely to find anything of significance, except perhaps one slightly abnormal blood test that later turns out to be a time-consuming and …

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