Commentary

Rush To Judgment! Or, What Is the "Truth"?

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Diagnosis requires clinical acumen and instinct. Randy Danielsen ponders how to balance the two.


 

As I get older and more experienced, with continued efforts to keep up to date on medical knowledge, I worry about the increase in medical errors and the possibility that some are caused by rushing to judgment on a diagnosis. Errors in clinical judgment, miscommunication, and technical mistakes are the three top reasons cited for medical liability cases.

During my clinical rotations as a PA student, it wasn't long before I became quite good at briefly presenting cases to the preceptors. I would describe my patients' presenting complaints and clinical findings for their consideration—just as I was taught in the didactic portion of school—and report them in an order that I thought was concise and relevant, building to an obvious diagnosis and, ultimately, to my brilliant life-saving treatment. Oh, how smart I felt at that moment!

One preceptor, Dr. M., would dutifully listen, then call me out for my lack of knowledge and naiveté and dispatch me back to the library and reference books (remember those?). Of course, preceptors were seldom wrong, so I'd study hard, learn some minutia that would clutter my confused and overwhelmed mind, and find I had rushed through the history and physical examination (H&P) without really knowing the patient—only his/her presenting symptoms. Back then, I focused more on identifying a condition or disease than on being my patient's health care provider.

Then another preceptor, Dr. T., would begin his shift and inevitably disagree with the previous guru. Dr. T.'s mantra was "What's the story?" followed by "Tell me the etiology and differential." That was usually followed by "You are being way too esoteric; REMEMBER, COMMON CONDITIONS ARE COMMON!" Oh my, what a catch-22. When is the first guy due back?

Now, four decades after my entry into the PA profession, I understand that our initial H&P might not elicit the "truth." After all, is not this information mostly judgmental, subjective—affected by trust, environment, communication skills, keen sense, and timing? Clinicians, patients, and students are all dealing with imprecise information.

We also know that the sheer amount of new scientific knowledge, understanding, change, and rebuttal makes it impossible for practicing clinicians to remain the repositories of standard of care. Why else do we have all these guidelines written by dozens of academicians with hundreds of references every year or two? It is just too much to stay on top of and remember.

So we have those in academe/research with their evidence-based medicine and those in the exam room, with their H&P information—which is better for making the diagnosis and treatment plan? And just in case you think this is a diatribe against academicians, you should know I believe we need those academic folks around to pay attention to the research and advances so they can tell us the "truth"—at least statistically speaking. (OK, OK, I know: Guidelines are developed by panels of researchers, academics, and clinicians, not just those in academe.)

Sometimes, though, the true issues, diseases, and illnesses that our patients have and need treatment for are not always evidence-based. Sometimes, they are vignettes or capsules in a person's life (see "A Hasty Diagnosis").

Those who champion evidence-based health care have controlled statistics to guide and direct us to treatment, diagnosis, and cost-effectiveness (maybe not in that order). But—and this is huge—our practicing clinician colleagues have patient stories and experiences that are perhaps just as credible.

After all, what is more evidence-based than real patients, taken care of by real clinicians, with real outcomes? This is not a subtle put-down of evidence-based medicine. Being evidence-based is certainly a framework for refining the information gained in the H&P.

But maybe we need to combine methods: to review the available literature (paying attention to the esoteric) while remaining focused on the patient's story and keeping that story simple.

Were Dr. M. and Dr. T., those two very different preceptors, "in cahoots"? Come to think of it, they were pretty smart. Maybe I should look them up, to say thanks and let them know that I'm still looking for answers and finding truth along the way.

I would love to hear your response to this. Please contact me at PAEditor@qhc.com.

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