One key to hospital medicine – skepticism


Category : Medical Rants

Benny Binion once said, "Trust everyone, but always cut the cards."

Over the past 10 years I have done ward attending as my sole clinical activity.  I average around 150 days a year making rounds.  As time goes on, I become more skeptical of any information that I do not collect myself.

People I do not trust:

  1. The ER physician
  2. The outpatient record
  3. The outside hospital
  4. The resident
  5. The intern
  6. The student
  7. My colleagues
  8. Myself!

I trust no one.  Too often patients are "billed" as having a certain diagnosis, but the true diagnosis is quite difference.  All the people I listed are honorable and doing their best.  But patients change over time.  The attending physician ALWAYS gets a more accurate history the next day.  The physical exam changes and becomes more clear.

The worst thing I can do is to accept everything at face value.  Many patients have straightforward diagnoses, but enough are tricky, that I must always assume that I should rethink the presentation.

We all make mistakes.  We must second guess ourselves daily.  Our patients deserve no less from us.  We should be persistent in our search for truth.

Many mystery novels use this as a technique.  They seem to finalize a resolution, but the stubborn detective insists that the data do not all fit just right.  That is our job.  Keep thinking; remain skeptical; when in doubt go back to the bedside, talk to the patient and examine the patient.  Remaining skeptical is the best way to minimize diagnostic errors.

Comments (7)

At some point, trust is required to remain sane.  I'd say I trust 90% of the people I work with 90% of the time.  And would hope they offer me the courtesy as well.

You miss the point Happy.

I was talking about trusting diagnoses, not trusting individuals. In fact, I probably did not write clearly or you did not read clearly. Generally, when you misinterpret, I did a poor job making my point.

I agree with rcentor. Patients and others (Doctors, Nurses, Students, Caregivers…) are usually trying to relay accurate information but often that information is incorrect. We all need to maintain a healthy share of skepticism.

This is what House means when he says "everyone lies."
My first attending when I was an MS3 used to say "after you make a plan, go back, collect more information, and change it."
The problem is not trust so much as "diagnosis lock" – an unwillingness to change workup, diagnosis or treatment simply because the patient isn't getting better… 

I always had a problem on rounds when I would ask residents how they knew someone had a certain disease or certain symptoms- not necessarily that what they were saying wasn't true but I was trying to get independent verification of information, not that they had simply copied down an ER diagnosis or recycled an old discharge note.
 Many took it as an insult,that I was doubting their word- I was – but not for the reasons they thought. This is the point Dr. C is making but it is usually one taught be experience  rather than teachers- and I'm afraid too many residents never figure it out. 

Ronald Reagan used to needle Gorbachev by quoting the Russian proverb "doveryai no proveryai".  Trust, but verify.  A large dose of skepticism is the mark of a real scientist.

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