Pearls of wisdom from Acute Medicine.co.uk – click here
The crime of doing unnecessary tests (”going fishing”)
There are many tests at your fingertips. Try to avoid blitzing the patient with every test you can think of, as many have a significant false positive rate. A ”positive” test can then lead to more (perhaps) dangerous tests. More tests can be added tomorrow. Blindly doing a Troponin T, or D-Dimer in anyone with chest pain, or Tumour Markers in someone with weight loss, is bad medicine. On the other hand, remember that the ED doctor will have a different view of tests to the Physician. He/she has to decide whether the person needs to come into hospital, you have to decide what”s wrong with them. Eg, blood cultures rarely change management on day one (and never affect the admission decision) but they do affect treatment on Day 2 or 3. So, if they have not done them (quite reasonably), you do them. And don”t criticise them for not doing them. Also, if you do a test, do it properly. You will get a much better report from a radiologist if you fill in the patient”s clinical information properly; eg ”Pleuritic chest pain ?cause, D-dimer = X, on OC pill, examination normal” will get a better report than ”Collapse ?cause”
The crime of (over) diagnostic certainty (ie arrogance)
An incorrect initial diagnosis may be copied. As you are often the first person to see the patient, there is a big danger that if you make an incorrect diagnosis, colleagues down the line, will merely copy it. A diagnosis of ‘Urosepsis’ and ‘Collapse?TIA’ is almost always wrong. More importantly, they can be diagnoses to pass on, as it is always easier to agree with the previous diagnosis, than challenge it. Most of us tend to come to a diagnosis quite quickly; often using pattern recognition, ”pigeon holing” the patient into a syndrome we have seen many times before (UTI, dementia, exacerbation COPD). Then we stick to that diagnosis, whatever later information comes through. This is dangerous. Sure, if you really are certain of a diagnosis, state it and act on it. Take the glory. But if you are not, keep your differential wide, ”cover your bases” (ie initiate treatment for your second most likely disease, and third, in some cases). Make sure your diagnosis introduces some uncertainty for the next reader (eg Acute confusional state, Cause uncertain, Probable sepsis, Possible UTI” is better than ”?UTI”.
vii. The crime of not putting the effort in for an easy diagnosis. Even at a junior stage it can be a bit easy. You have been a doctor for a year, you know the patient has lobar pneumonia, you have seen 20 before. You have seen the CXR before you see the patient, to save time. You cut corners. You don’t check the antibiotics you have prescribed are given. You don”t check for allergies. You forget to pass on a crucial bit of information (eg previous episode same part of same lung; raising possibility of a foreign body). Things go wrong with an easy case too. Concentrate on the easy cases too, they may not be as easy as they seem. Or as Heraclitus of Ephesus (535–475 BC) put it, “You could not step twice into the same river”
Grey case thinking (‘What it’s not thinking’)
Sir Arthur Conan Doyle wrote “It is an old maxim of mine that when you have excluded the impossible, whatever remains, however improbable, must be the truth”. How does this idea apply to medicine? Well, the impossible is often quite easy to exclude, leaving you with many probabilities and improbabilities. But, which is the truth? Whether the patient is frail and elderly like the patient above or not, and the senior review also does not come up with a clear diagnosis, it is best to rethink the patient as a ‘grey case’. In other words, become a detective, pursue different lines of enquiry. And when it comes to treatment (again) ‘cover your bases’. Eg rather than thinking what is the diagnosis and treatment, ask yourself why is A or B not the diagnosis? And why are you not treating it with X or Y? And if there is no reason not to give treatment X or Y, give it
