Blog | Friday, December 21, 2018

The scope of diagnosis, some thoughts after attending #DEM2018

This past weekend I participated in the Society to Improve Medical Diagnosis annual meeting. I saw many old and new friends. Going to a meeting often stimulates thinking. Because we often talk about diagnostic errors, we must first define diagnosis. As I listened to talks, observed posters, and talked with colleagues a broader concept occurred. Probably others have considered this, and if so, please send me the reference.

Diagnosis has several levels. A patient coming to see either a primary care physician, cardiologist, emergency physician or someone else (including urgent care, nurse practitioners, and physician assistants) because they have significant chest pain triggers a search for a diagnosis. Similarly, a patient with 20-pound weight loss (plus or minus other symptoms) might trigger a search for a diagnosis. These examples of diagnosis are rather clear.

But the situations I began to think about are rather different. Let's outline 3 such examples:
1. A patient has a sodium of 120; the diagnostic question is why. We first need to understand the immediate cause of the hyponatremia, but then we often need to examine the underlying diagnosis.
2. A patient with known COPD comes to see you for worsening dyspnea. Sometimes we label that as COPD exacerbation, but what is the real diagnosis causing the exacerbation?
3. A patient presents with a creatinine of 3 with a known recent creatinine of 1.2. Often we make the “diagnosis” of AKI, but that is not a diagnosis. Something caused that increased creatinine, and we should careful go through a diagnostic process to find the cause.

I wonder if we could learn about diagnostic errors by looking at such situations (I am certain that you can add many common situations to this list). How we approach getting to the underlying diagnosis says something about our diagnostic process?

As a clinician educator, I often spend significant time with the students, interns and residents on such concerns. Do you? Do you even consider such situations as diagnostic dilemmas?

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.