Blog | Monday, April 2, 2018

Many medical nouns need adjectives


Last week on Twitter I wrote a series of tweets about necessary qualifiers. Here are the tweets, which represent an incomplete sample of the problem:
1st tweet on importance of qualifiers w/ “diagnoses”. Do not label the patient as COPD exacerbation without saying why: Differential includes acute bronchitis, pneumonia, pneumothorax, left side heart failure, anemia, opiates, PE etc.
2nd qualifier tweet – Never tell me the patient has CKD without giving me the stage and the cause. Corollary – do not give me the eGFR for patients with AKI – the estimates do not work with increasing creatinine levels
3rd qualifier tweet – when the patient has diabetes mellitus – identify type and duration – type I and type 2 have some different associated problems – duration suggests looking for certain complications. Mention known complications
4th qualifier tweet – don't label the patient CHF – rather heart failure with modifiers – systolic dysfunction (provide the ejection fraction), or valvular or preserved ejection fraction or right heart failure – perhaps some others –
5th qualifier tweet – cirrhosis – secondary to (alcohol, hep C or whatever), previously known complications and report MELD score with labs

These examples are very important, at least in my mind. Just in case I have not made my point, the reason for these examples comes from seeing lists of “diseases” in the past medical history without any sense of the importance of each disease. As a confirmed skeptic, I want more information than a label. What is the evidence for the diagnosis, and where in the spectrum does this patient lie.

To take this a bit further, how often do you see a patient labeled as having COPD without any confirmatory testing. Sometimes the COPD patient really has chronic restrictive lung disease, or sleep apnea. We do need pulmonary function studies to understand, and properly treat the patient.

Oncology has practiced this for many years. I suspect most subspecialists understand this for their disease sets, but too often primary care physicians, hospitalists, and learners leave out these modifiers.

Sherlock Holmes once said, “It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.” Without knowing the severity of disease we could easily fall into advancing theories that do not make sense.

Please feel free to add to this admittedly biases and shortened list.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.