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One of the perks that a maturing physician can enjoy is a declining frequency of unexpected clinical outcomes. As the face-to-face patient encounters accumulate over the years, repeating patterns begin to emerge. Ironically, while the older physician notices that his memory for specifics is declining, he may find himself saying more often, “I've seen something like this before.”
In fact, if he can remain objective and engaged with the passing multitude, the experienced physician may develop diagnostic skills that can make him appear psychic. Many years ago I remember being in awe of one of our older physicians who could arrive at the correct diagnosis in half the time and usually with none of the lab or x-ray studies that his young associates required. In addition, his therapeutic interventions seemed to fail far less often than mine.
Sadly, I haven't come close to achieving that old guy's uncanny diagnostic skills, but I've been seeing patients long enough to appreciate how easy things are when my experience includes the right stuff. And, how uncomfortable I feel when I am clueless and floundering even after taking a thorough history and physical.
There is no substitute for an accurate diagnosis or the correct answer to a parent's question. The wrong path can trigger an expensive and time-consuming cascade of lab tests, x-rays, and poorly focused consultations. Therapeutic interventions may be recommended that are likely to be ineffective or, worse yet, that tip their own domino slide of side effects and confusing symptoms.
For example, let's take the everyday scenario of the 18-month-old who is in the middle of the community-wide viral gastroenteritis. Her vomiting has subsided after 2 days but the diarrhea is still voluminous. Her physician does a thorough exam including a weight. He determines that there is no immediate danger of dehydration and suggests that the family continue the oral electrolyte solution and suggests a “bland diet.” Unfortunately, the physician fails to ask what the family is currently giving the child to eat and drink.
The parents, believing that the oral electrolyte solution is a medication, continue to give the child fruit juice as her primary beverage in addition to the solution. The diarrhea continues to rage and 2 days later the family returns to the emergency department after hours. The ED physician orders a battery of tests including stool cultures and a survey for intestinal parasites. The bill for the hospital services exceeds $400. And, when the family finally returns to the pediatrician, the child's bottom is raw and bleeding.
It is tempting to blame the parents for not considering that if the pediatrician had previously recommended fruit juice as a remedy for constipation, then juice would probably be a bad idea when the child has diarrhea. However, I have witnessed the scenario enough times to remove this from my list of basic assumptions. After several unfortunate experiences, I now ask all parents exactly what they are giving their children now and I specify what they should and should not give their children until the diarrhea subsides.
So what's the big deal? In the whole spectrum of medical mistakes, this physician's omission is so trivial that it will never appear as a statistic. But, it does make me shiver to think how big the iceberg of medical errors must be.
The dilemma I struggle with occurs when I am eavesdropping and I hear what I know is the wrong answer being given to a parent. Of course, when the error may result in pain or injury, I speak up promptly. However, when the fallout of the imperfect advice will be limited to a loss of time or money, I bite my tongue. And, I hope I will remember at some later time to tactfully discuss the scenario. The problem is that neither tact nor memory is my strong suit. I don't want to be seen as a nitpicking old codger … all the time.
One of the perks that a maturing physician can enjoy is a declining frequency of unexpected clinical outcomes. As the face-to-face patient encounters accumulate over the years, repeating patterns begin to emerge. Ironically, while the older physician notices that his memory for specifics is declining, he may find himself saying more often, “I've seen something like this before.”
In fact, if he can remain objective and engaged with the passing multitude, the experienced physician may develop diagnostic skills that can make him appear psychic. Many years ago I remember being in awe of one of our older physicians who could arrive at the correct diagnosis in half the time and usually with none of the lab or x-ray studies that his young associates required. In addition, his therapeutic interventions seemed to fail far less often than mine.
Sadly, I haven't come close to achieving that old guy's uncanny diagnostic skills, but I've been seeing patients long enough to appreciate how easy things are when my experience includes the right stuff. And, how uncomfortable I feel when I am clueless and floundering even after taking a thorough history and physical.
There is no substitute for an accurate diagnosis or the correct answer to a parent's question. The wrong path can trigger an expensive and time-consuming cascade of lab tests, x-rays, and poorly focused consultations. Therapeutic interventions may be recommended that are likely to be ineffective or, worse yet, that tip their own domino slide of side effects and confusing symptoms.
For example, let's take the everyday scenario of the 18-month-old who is in the middle of the community-wide viral gastroenteritis. Her vomiting has subsided after 2 days but the diarrhea is still voluminous. Her physician does a thorough exam including a weight. He determines that there is no immediate danger of dehydration and suggests that the family continue the oral electrolyte solution and suggests a “bland diet.” Unfortunately, the physician fails to ask what the family is currently giving the child to eat and drink.
The parents, believing that the oral electrolyte solution is a medication, continue to give the child fruit juice as her primary beverage in addition to the solution. The diarrhea continues to rage and 2 days later the family returns to the emergency department after hours. The ED physician orders a battery of tests including stool cultures and a survey for intestinal parasites. The bill for the hospital services exceeds $400. And, when the family finally returns to the pediatrician, the child's bottom is raw and bleeding.
It is tempting to blame the parents for not considering that if the pediatrician had previously recommended fruit juice as a remedy for constipation, then juice would probably be a bad idea when the child has diarrhea. However, I have witnessed the scenario enough times to remove this from my list of basic assumptions. After several unfortunate experiences, I now ask all parents exactly what they are giving their children now and I specify what they should and should not give their children until the diarrhea subsides.
So what's the big deal? In the whole spectrum of medical mistakes, this physician's omission is so trivial that it will never appear as a statistic. But, it does make me shiver to think how big the iceberg of medical errors must be.
The dilemma I struggle with occurs when I am eavesdropping and I hear what I know is the wrong answer being given to a parent. Of course, when the error may result in pain or injury, I speak up promptly. However, when the fallout of the imperfect advice will be limited to a loss of time or money, I bite my tongue. And, I hope I will remember at some later time to tactfully discuss the scenario. The problem is that neither tact nor memory is my strong suit. I don't want to be seen as a nitpicking old codger … all the time.
One of the perks that a maturing physician can enjoy is a declining frequency of unexpected clinical outcomes. As the face-to-face patient encounters accumulate over the years, repeating patterns begin to emerge. Ironically, while the older physician notices that his memory for specifics is declining, he may find himself saying more often, “I've seen something like this before.”
In fact, if he can remain objective and engaged with the passing multitude, the experienced physician may develop diagnostic skills that can make him appear psychic. Many years ago I remember being in awe of one of our older physicians who could arrive at the correct diagnosis in half the time and usually with none of the lab or x-ray studies that his young associates required. In addition, his therapeutic interventions seemed to fail far less often than mine.
Sadly, I haven't come close to achieving that old guy's uncanny diagnostic skills, but I've been seeing patients long enough to appreciate how easy things are when my experience includes the right stuff. And, how uncomfortable I feel when I am clueless and floundering even after taking a thorough history and physical.
There is no substitute for an accurate diagnosis or the correct answer to a parent's question. The wrong path can trigger an expensive and time-consuming cascade of lab tests, x-rays, and poorly focused consultations. Therapeutic interventions may be recommended that are likely to be ineffective or, worse yet, that tip their own domino slide of side effects and confusing symptoms.
For example, let's take the everyday scenario of the 18-month-old who is in the middle of the community-wide viral gastroenteritis. Her vomiting has subsided after 2 days but the diarrhea is still voluminous. Her physician does a thorough exam including a weight. He determines that there is no immediate danger of dehydration and suggests that the family continue the oral electrolyte solution and suggests a “bland diet.” Unfortunately, the physician fails to ask what the family is currently giving the child to eat and drink.
The parents, believing that the oral electrolyte solution is a medication, continue to give the child fruit juice as her primary beverage in addition to the solution. The diarrhea continues to rage and 2 days later the family returns to the emergency department after hours. The ED physician orders a battery of tests including stool cultures and a survey for intestinal parasites. The bill for the hospital services exceeds $400. And, when the family finally returns to the pediatrician, the child's bottom is raw and bleeding.
It is tempting to blame the parents for not considering that if the pediatrician had previously recommended fruit juice as a remedy for constipation, then juice would probably be a bad idea when the child has diarrhea. However, I have witnessed the scenario enough times to remove this from my list of basic assumptions. After several unfortunate experiences, I now ask all parents exactly what they are giving their children now and I specify what they should and should not give their children until the diarrhea subsides.
So what's the big deal? In the whole spectrum of medical mistakes, this physician's omission is so trivial that it will never appear as a statistic. But, it does make me shiver to think how big the iceberg of medical errors must be.
The dilemma I struggle with occurs when I am eavesdropping and I hear what I know is the wrong answer being given to a parent. Of course, when the error may result in pain or injury, I speak up promptly. However, when the fallout of the imperfect advice will be limited to a loss of time or money, I bite my tongue. And, I hope I will remember at some later time to tactfully discuss the scenario. The problem is that neither tact nor memory is my strong suit. I don't want to be seen as a nitpicking old codger … all the time.