Diagnosis – observation


Category : Medical Rants

This story rings too true – Missed diagnosis in the ER, and the need to look

The job of ER doc is very difficult.  They must try to find needles in haystacks.  They also work under time pressure from too many patients.  This confessional does make a point though.  Diagnosis is difficult and important.  The writer missed a diagnosis because he never thought of that possibility.  The context was wrong, and likely the patient did not give a great history.

Several readers sent me this link – Physician Revives a Dying Art: The Physical

Bedside teaching and especially physical diagnosis need some celebrities, and Dr. Verghese clearly is a celebrity.  But the article indirectly implies that he is alone doing this.  We have many similar attending physicians in this country, but they only have local fame amongst medical students and residents.  Our school (and many others) teach an advanced physical diagnosis course for 4th year students.  Too few students take the courses, but we should acknowledge that many attending physicians are trying hard to do exactly what Dr. Verghese is doing.

But the schools do not emphasize clinical teaching strongly enough.  Most medical schools become obsessed with research dollars and clinical income.  Teaching becomes the red headed step child.

Kudos to Stanford and Dr. Verghese.  But remember it should be more than one star at each institution.

Comments (1)

On the meningitis case:
I don't know whether I would have diagnosed it- but I can tell you one thing after working with these type of patients for 35 years – if an alcoholic came in with a stiff neck and I didn't consider meninigitis and he had it  I never, ever in a million years would say I wouldn't do anything differently if I missed it. I would be saying, I should have done it. Why didn't I? How are you ever going to learn if you don't confront situations like this? What are you going to tell the students? a guy , probably immunocompromised comes in with a stiff neck, and we didn't tap him and he had meninigitis and we did everything right? At least tell them next time we will think about tapping him.
You can rationalize anything but the point is that the tough ones are the ones where there is a red herring. That's the case here. You should do it differently next time or at least think about it differently next time. It's a hard job, and there is a sort of arrogance about that type of attitude- I missed a meninigits but I did everything right. That's nonsense. Maybe you have to tap 20 alcoholics with torticollis to get one meninigitis but you are saving one life. I will bet money that ER doc has tapped people with less indication than this. 
 Re Verghese- he's the man but the fact is that physical exam has limited value in many sittuations today .Neurologic exams and abdominal exams – yes – but it's like cursive writing. There is a place for it, everyone should learn it, but it just doesn't have the utility it did in the past and never will again.  (By the way, good physical exam  didn't help the meninigitis patient – eye can not see what the brain doesn't think of)   

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