Over the years, I have written about the short head and long tail. For those who have not considered the long tail, it refers to the approximately 15-20% of patients who are not routine. For each chief complaint, some patients will not have one of the “usual suspect” diagnoses. Our job is to recognize when we need to think of more usual diagnoses.
Experts can tell you what “red flags” lead them to slow down. I did an interview that will likely appear on television (I will link the piece when it becomes available). The interviewer asked me what advice I would give to moms about their high school or college aged children with a sore throat. I have clearly thought about the sore throat “red flags”, so I quickly answered:
1. Worry about a sore throat that is worsening or not improving in 3-5 days.
2. Worry about the “worst sore throat ever”
3. Worry about night sweats
4. Worry about rigors
5. Worry about unilateral neck swelling
For many problems I have a good list of “red flags”. I had to learn these over time. I do not remember my excellent residents and attending physicians teaching them.
Knowing “red flags” can help us know when to rev up the diagnostic engine. This requires us to really understand the natural history of each diagnosis. When we assume a diagnosis, and the patient's course deviates from the textbook, we likely have the wrong diagnosis.
Each specialty and each sub-specialty have unique cues that should make us uncomfortable. We who focus on clinical education should know them and teach them explicitly.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.