Diagnosis: the forgotten ICU procedure

Intensive care medicine runs on numbers. Positive end-expiratory pressure of 6 or 8 cmH₂O, 250 mL of saline or 500 mL of Ringer’s lactate, etomidate or ketamine for induction, high-flow nasal oxygen or conventional oxygen therapy, pressure-support ventilation or a T-piece trial. These are the questions that fill conference halls, guideline documents and journal pages, and in a new commentary published in Intensive Care Medicine, intensivist Damien Contou argues that this obsession with fine-tuning has come at a cost: the diagnostic act itself, he writes, has become the forgotten ICU procedure.

The commentary, part of the journal’s “From the Inside” series and published on 29 October 2026, does not report new clinical data. It is a reflective essay, and its central claim is deliberately provocative. Critical care thrives on protocols, waveforms, algorithms and screens, and the literature is filled with studies examining ever more subtle differences in practice. Some of those refinements may even improve outcomes. Yet, as Contou observes, patients rarely die from an imperfect PEEP setting. While many patients die despite the right diagnosis and appropriate treatment, others die because the diagnosis was missed, delayed, or never reconsidered.

The essay paints a familiar ICU paradox. A patient may be impeccably ventilated, exquisitely monitored and supported by the most advanced technologies available. Physiological variables may look reassuring on the monitor. The patient may still be dying, because treatment has focused on optimizing physiology while the underlying diagnosis remains unrecognized. No degree of technical excellence, the author argues, can compensate for diagnostic failure.

Contou illustrates the point with the kinds of questions that should haunt every intensivist: What explains this delirium? Why this pulmonary edema? What lies behind this acute respiratory distress syndrome? Why this COPD exacerbation, this hyponatremia, this sudden diabetic ketoacidosis? Why is the fever back? Is it really ventilator-associated pneumonia? The answer, he writes, rarely comes from a monitor.

Instead, the commentary locates diagnosis in quieter, less glamorous work. Critical care continues when a chart is reopened in the middle of the night, when a patient is examined again long after everyone believes the case has been solved, when a family member mentions a detail that changes everything, or when a phone call to a primary care physician uncovers a forgotten history. It continues when an old radiograph or electrocardiogram is retrieved from the archive, when a previous creatinine level buried deep in the records reveals that what seemed acute is not, when a medication list no one had carefully reviewed finally gets read, and when a timeline is reconstructed event by event until the pieces fit together.

A striking feature of the essay is its admission that this most important act in critical care may never be captured by a randomized trial. No trial will ever quantify the contribution of curiosity, clinical reasoning, perseverance and doubt to the diagnostic process. That unmeasurability, the author implies, is precisely why diagnosis risks being neglected in a specialty that increasingly defines itself by measurable physiological targets and protocolized interventions.

The commentary also warns that technology can pull clinicians away from the bedside, where patients, families and diagnostic clues actually wait. Even in the era of artificial intelligence, Contou writes, diagnosis still depends on curiosity, persistence, humility and the refusal to stop asking questions—again and again, until the diagnosis emerges. Screens, curves and algorithms can easily draw attention away from that fundamental encounter.

To anchor the argument, the author invokes Professor Georges Offenstadt, who led the Medical Intensive Care Unit at Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, from 1997 to 2010, and who used to remind his trainees: “Soyons de bons ouvriers”—let us be good craftsmen. Before embracing sophistication, the essay argues, clinicians should first make sure the fundamentals are right: listening, examining, verifying, rechecking, retrieving missing information, doubting, and returning to the bedside. The diagnosis is not always hidden in complexity; it is often buried beneath neglected basics.

The essay closes with a simple proposition: critical care medicine demands both technical expertise and diagnostic reasoning, and each deserves the same rigor. As a commentary rather than a research study, it offers no trial evidence and no new interventions. Its value lies in the challenge it poses to a specialty that celebrates its ventilators and infusion pumps while, the author contends, quietly forgetting that the most consequential procedure in the ICU may be the act of asking, once more, what is really wrong with this patient.

Subject of Research: An ICU commentary arguing that diagnostic reasoning is neglected relative to technical optimization in critical care

Article Title: Diagnosis: the forgotten ICU procedure

Article References: Contou, D. (2026). Diagnosis: the forgotten ICU procedure. Intensive Care Medicine. https://doi.org/10.1007/s00134-026-08609-w

Image Credits: AI Generated

DOI: 10.1007/s00134-026-08609-w

Keywords: intensive care, diagnosis, critical care medicine, diagnostic reasoning, ICU, commentary, clinical reasoning, ventilation, bedside examination, Intensive Care Medicine, forgotten, procedure