Friday, November 20, 2015
Getting diagnostic help through sharing the patient's story
Recently, we had a new patient admission whose presentation confused the entire team. We developed a differential diagnosis, but really did not have great confidence that we were moving in the right direction. We thought we had a good idea of what diagnoses we could not afford to miss. We ordered a few tests to exclude those can't miss diagnoses, but all the tests did not provide an answer. We accomplished this strategy within a few hours.
My resident and I happened upon 2 physicians in the physician's lunch room. One was a resident; another, a subspecialist. Being confused, we shared the story with our colleagues.
The other resident suggested a possibility that we had not considered. I immediately pulled up DynaMed Plus (disclaimer, I am on the editorial board and all ACP members get DynaMed Plus for free for the next 2 years) to investigate this possibility. I think that I had heard about the possibility, but unfortunately had not really learned enough on that subject.
The research confirmed the suggestion. We proceeded to make this possibility our #1 diagnostic target, because it is very treatable and potentially deadly if we missed it.
Of course, the resident was correct. Our lunch conversation made a potentially long and hazardous hospitalization much shorter and with a great outcome for the patient.
As I think about diagnostic dilemmas, I realize that I often “run the story” by colleagues, residents and even students. Sometimes the process of telling the story helps me better understand; sometimes the listener asks a key question; often the listener expands the differential diagnosis.
A couple of months ago, a former student (now an intern) approached me after a teaching conference. He wanted to share a patient story to see if I had any good ideas. His resident and he told me the story. In that instance, I had the proper knowledge to help, and once again the patient benefited.
In both cases, I have told the stories multiple times since. In the first case, most physicians go down the same paths that we originally did. Yesterday, I presented the story to a chief medical resident who had seen a similar patient as a student. He got the answer immediately.
For the second case, few people know the information that allowed me to point the team in the right direction. The presentation was 1 that I particularly had thought about and studied because I have a passion for acid-base and electrolytes.
Our sports role models should not be individual sport champions, but rather the “glue guys” in team sports. ”Glue guys” strive at all times to do whatever is necessary to help the team. The enemy is ignorance of the correct diagnosis. Victory is getting to the proper diagnosis. We cannot afford to have ego about how we get there, rather we must take advantage of interpersonal “crowd sourcing” if that helps the patient.
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.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
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Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
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Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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