Sort out vs rule out

4 Nov
2005

I am currently attending the Canadian Society of Internal Medicine meetings in Toronto. I had occasion to chat with Dr. David Sackett (of clinical epidemiology fame). We were discussing GIM from an international perspective.

He pointed out that general internists develop skills in “sorting out” a patient’s problems, medications, etc. In contrast, subspecialists tend to develop skills in “ruling out” their organ system.

While this distinction is a bit pithy and cute, I like it a great deal – and plan to use it often. We have a difficult time developing quality measures around this important skill. Yet, many patients arrive at our hospital or office without a diagnosis. Therefore, our greatest skill is undervalued because it is so difficult to measure.

viagra
free viagra
buy viagra online
generic viagra
how does viagra work
cheap viagra
buy viagra
buy viagra online inurl
viagra 6 free samples
viagra online
viagra for women
viagra side effects
female viagra
natural viagra
online viagra
cheapest viagra prices
herbal viagra
alternative to viagra
buy generic viagra
purchase viagra online
free viagra without prescription
viagra attorneys
free viagra samples before buying
buy generic viagra cheap
viagra uk
generic viagra online
try viagra for free
generic viagra from india
fda approves viagra
free viagra sample
what is better viagra or levitra
discount generic viagra online
viagra cialis levitra
viagra dosage
viagra cheap
viagra on line
best price for viagra
free sample pack of viagra
viagra generic
viagra without prescription
discount viagra
gay viagra
mail order viagra
viagra inurl
generic viagra online paypal
generic viagra overnight
generic viagra online pharmacy
generic viagra uk
buy cheap viagra online uk
suppliers of viagra
how long does viagra last
viagra sex
generic viagra soft tabs
generic viagra 100mg
buy viagra onli
generic viagra online without prescription
viagra energy drink
cheapest uk supplier viagra
viagra cialis
generic viagra safe
viagra professional
viagra sales
viagra free trial pack
viagra lawyers
over the counter viagra
best price for generic viagra
viagra jokes
buying viagra
viagra samples
viagra sample
cialis
generic cialis
cheapest cialis
buy cialis online
buying generic cialis
cialis for order
what are the side effects of cialis
buy generic cialis
what is the generic name for cialis
cheap cialis
cialis online
buy cialis
cialis side effects
how long does cialis last
cialis forum
cialis lawyer ohio
cialis attorneys
cialis attorney columbus
cialis injury lawyer ohio
cialis injury attorney ohio
cialis injury lawyer columbus
prices cialis
cialis lawyers
viagra cialis levitra
cialis lawyer columbus
online generic cialis
daily cialis
cialis injury attorney columbus
cialis attorney ohio
cialis cost
cialis professional
cialis super active
how does cialis work
what does cialis look like
cialis drug
viagra cialis
cialis to buy new zealand
cialis without prescription
free cialis
cialis soft tabs
discount cialis
cialis generic
generic cialis from india
cheap cialis sale online
cialis daily
cialis reviews
cialis generico
how can i take cialis
cheap cialis si
cialis vs viagra
levitra
generic levitra
levitra attorneys
what is better viagra or levitra
viagra cialis levitra
levitra side effects
buy levitra
levitra online
levitra dangers
how does levitra work
levitra lawyers
what is the difference between levitra and viagra
levitra versus viagra
which works better viagra or levitra
buy levitra and overnight shipping
levitra vs viagra
canidan pharmacies levitra
how long does levitra last
viagra cialis levitra
levitra acheter
comprare levitra
levitra ohne rezept
levitra 20mg
levitra senza ricetta
cheapest generic levitra
levitra compra
cheap levitra
levitra overnight
levitra generika
levitra kaufen

Related posts:

  1. More evidence against the 4 hr rule
  2. Remembering the Wizard’s First Rule
  3. Nails in the coffin – the 4 hour rule
  4. New Medicaid rule blocks citizens from coverage

Related posts brought to you by Yet Another Related Posts Plugin.

5 Responses to Sort out vs rule out

Avatar

matthew md

November 4th, 2005 at 6:44 pm

Not only general internists, but also general surgeons follow the “sorting out” criteria. I agree that not enough credit is given to these potential diagnostic dilemmas. Nonoperative determinations are just as thought provoking (and angst-producing) as “taking a patient to surgery” and yet the reimbursement does not adequately consider the cognitive process involved by the surgeon.

Avatar

Dr. Bob

November 6th, 2005 at 5:40 pm

I think this is also what seperates out the physicians from the midlevel providers. Some nurse practicioners claim they can do as good a job as primary care docs. I think they can make some claims in this area when the diagnosis is certain and there are well designed clinical protocols for management. The mistakes I see them making though are when the diagnosis has not been made yet, when the disease has an unusual presentation, or when there are complications or unexpected response to treatment. The length of their training doesn’t expose them to enought variation and amount of pathology. As the old saying goes – “you can’t diagnosis it if you’ve never heard of it”. I think this is one of the areas where primary care physicians shine.

Avatar

tina

November 8th, 2005 at 1:08 pm

Hi Dr.Bob,

I went to the PCP the other day with all the lymph nodes on the left side of my head swelled up, a fever, and weakness on the left half of my body. She told me it was TMJ and I had no infection, told me the lymph nodes weren’t swollen. Rather odd as I live in this body every day and I don’t normally have painful puffy lumps where my lymph nodes are. TMJ is some crazy stuff.

I have to say that previous interactions with NPs have been better than with MDs. They have more time to listen and are willing to say “I have no idea”. Time is the factor. The PCP was so busy not listening that she gave me an answer that makes no sense. Every visit is about getting me out the door quickly with as many meds as possible. I didn’t need meds the other day. I needed to make sure I didn’t have menengitus or something else really odd that I would be unaware of.

Now other people in the office are feeling sick so it seems my TMJ is contagious.

I am actually looking for an NP or something along those lines as I need to in the care of someone who can stop and think for a minute and listen to me without questioning everything I say.

My experience with endos confirms the above ruling out phenomena. When Dr. Satan ruled out the endocrine system as the root of the problem she was at a loss. She sent me to a cardiologist and then wanted me to go to a neurologist. She had no ability to think in a global way. The cardiologist could only tell me “it’s not your heart-its something endocrine”. Did these guys miss out on the rest of med school or something?

Avatar

matte

November 9th, 2005 at 1:52 am

Diagnsotic skills all require careful attention and time to interview, examine, test and rexamine. low Reimbursements unfortunately discourage this.

as for diagnostic skills offerred by a MD/DO or NP ?
some MD’s/DO’s are great, some are terrible.
some NP’s are great, some are terrible.

New England journal of medicine recently had an article showing that Pt’s hospitalized late in the week had increased risk of having a bad outcome. This indicates the fact that people do get fatigued and fatigue can influence the quality of health care.

no surpise here…but this does highlight how other influences other than professional degree affect outcomes.

Tina , good luck with your search for a good provider.

Avatar

lymph nodes

March 18th, 2008 at 8:46 am

It cannot be ignored, that nearly all Breast Cancer Tumors occur in the upper outer quadrant of the breast area, this is where the Lymph Nodes are located..

Comment Form