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Saturday, 13 February 2016

Why should we always think of the rare?

Doctors working in the field of internal medicine and virtually any other medical specialty, tend to keep a more or less fixed rhythm of work, utilizing essential knowledge, effective clinical methods and targeted lab and imaging work-up plans.

There is subconscious drive towards maintaining a plateau of effort as things seem to be as they were the day before. 

A patient presents with headache. Look for features of migraine, and tension headache, and examine the head and neck, check blood pressure, and order CT scan when needed. 

The next day, a second patient presents with so and so , look for bla bla and order bla bla.
A killer daily routine that may only end up with a clinical tragedy to awaken the physician’s insight to the reality of medicine, although it may come after a patient passed away! That’s too late.

What happened? Actually nothing! The question should be like that:  What has not happened?
What hasn't happened is the action based on broad vision approach and timely change in the direction of thinking, taking in consideration a scientific way of expectation, no harm if mixed with the flavor of experience. 

When your cardiac patient tells you that he or she experiences heartburn that doesn't ease with anti acids, you will probably think of myocardial ischemia besides thinking of the possibility of heading to ambulatory esophageal pH monitoring. But, what if both of these are then found not to be responsible for the symptoms? 
You must have been prepared to look for alternative scenarios when the existing become clearly not applicable.

Plan A should be followed by plan B, C, D , and even Z.
The last patient with heartburn may be, after exhausting work-up, found to have functional GERD!
This is not rare, though it may take extra resources to say yes or no.
What if we are talking about a real rare diagnosis? And what if the there are multiple possible rare diagnoses?
Here we are obliged to work in a different way, to keep our mental balance throughout the whole clinical case approach.

Like politicians, doctors must exhibit extreme flexibility in dealing with variable circumstances, and keep an eye, not necessarily taking action, on every minute detail in the current problem being evaluated and going to be solved.

Action or actions must go parallel to what mind says, and largely governed by priority. Coming steps must be expected and unexpected outcomes MUST BE EXPECTED.

I don’t mean when you are evaluating a patient, you must put a list of all possible rare diagnoses and to start excluding them one after the other. This seems silly. It’s actually silly.

A patient with particular presenting clinical features, may have one of these (I don’t know if there are other possibilities):
A common diagnosis/clinical condition 
An uncommon diagnosis/clinical condition
A rare diagnosis/clinical condition
Or may have nothing!

Then we start playing like this:
Does it fit a common diagnosis/clinical condition?
If yes, that's it, and proceed to the confirmatory test.
If no, does it fit any alternative uncommon diagnosis/clinical condition?
If yes, confirm it.
If no, you can put the list of rare.

But one thing important to mention. There are common features, as well as rare features for the common diagnoses/clinical conditions.
This again should be solved before jumping to the uncommon.
To make things worse, when you find your self drown in the rarest, you may find your self dealing actually with a rare presentation of a rare diagnoses/clinical condition!
That’s the worst scenario ever among those highlighted above.

If you are “luckily unlucky” you may reach this stage, meaning that you are an excellent clinician.
If you are “unluckily lucky” , you will never see these horrors, meaning that you are a clinician who is driven by his/her subconscious mind to work in a constant pace of rhythm, just to have a “clinical day” that’s not different from the preceding nor the coming.

The whole process of wise diagnostic approach, requires a lot of practice to polish. What we learn every day as physicians depends on how far can we see (this has nothing to do with refractive errors).

For every single patient you are going to evaluate, you must be prepared for the worst (and, of course for the best). 

No one knows how the end will be, but we can outline what things can be, with the first few minutes of patient’s interview.

Appropriate preparedness is the key to success, and the not random bombarding of what ever you see to end up just with globus hystericus as your poor,  lonely diagnosis!

Finally, textbooks are full of rare diagnoses. A smart physician’s clinical notes are likely to contain some. 
A “subconscious mind- driven” physician, is unlikely to have come across with any of them.


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