From a young age, children learn to “Stop, Look, and Listen” when crossing the street. Clinicians would do well to live by these words in the realm of clinical reasoning.
Drowning in data
Clinical medicine is fraught with information overload. We are inundated with data at every turn, a lot of which is extraneous and not helpful as we push to make a diagnosis. In the midst of this turbulent ocean of symptoms, signs, and test results, one ponders the deeper question: What is signal and what is noise?
We’ve all heard learning in medicine described as “drinking from a firehose.” I would argue this is too passive an analogy for what learners do each day on the wards. Think instead of a process that requires the utmost attention and care, lest we make a dangerous wrong turn—or three. A process of movement, of navigation, of crossing from point A to point B. Medicine is like dodging traffic. You need a heads-up, engaged frame of mind as you leave the fire hydrant on the curb and step into the action, and no, GPS won’t help.
Picture a busy intersection during rush hour in New York City that you need to cross. How can you (educator/physician/provider), help the (learner/team/patient) reach the other side, arriving at the destination (diagnosis)—safely and effectively? This line of thinking hit home for me recently during a case as I attended on the wards.
One step forward, two steps back
The morning progressed just like any other day’s rounds as our teaching team circled around the computer and discussed an overnight transfer from the ICU. The patient received treatment for a severe bloodstream infection and had recovered well. But before the team had a chance to settle on a “glass half full” perspective, a new concerning data point grabbed their attention: our patient’s neutrophil count was now zero.
“It’s from Vancomycin,” offered the intern on the team. “The MICU team and ID both felt strongly about it.”
As is often the case on the wards, we had more questions than answers. Everyone chimed in:
“Why is only one cell line affected instead of the usual two or three?” asked the medical student.
“Right, don’t medications and sepsis suppress bone marrow indiscriminately?” responded the resident.
“How convinced are we that the neutropenia is from antibiotics when he had been on Vancomycin for days?” our pharmacist asked.
I was happy to keep this line of rhetorical questions going—it felt like keeping a volleyball up in the air. I lobbed one to the group:
“What is the mechanism of vancomycin-induced neutropenia, so that we might prevent it from recurring going forward?”
While this hallway discussion was a helpful, even fun, team exercise, there’s a problem with formulating the assessment and plan before entering the room. We involve everyone but the most important member of the team: the patient.
“Doctors, this tongue issue is really bothering me.”
As we gathered around the patient’s bedside, he pointed to several shallow ulcers over the dorsal aspect of his tongue, wincing in pain. This was new information, nothing that had come up in our discussion outside. As we collectively struggled to find an explanation, I realized how often we as physicians focus on answering the How—the subjective symptoms, feelings, and emotions with which patients register their complaints—while what they really wonder and ask us for is: Why?
When we give proper attention to a patient’s understanding of her illness, the Why may actually be revealed in the How.
Sleep on it
I found myself later that night having what I call “pillow thoughts”—that moment when an unresolved clinical question from the day catches you just before you fall asleep. For some reason our patient’s statement about his “tongue issue” kept ringing in my ears. I gave up counting sheep and started doing a literature search instead, when suddenly the answer was right there—in the very title of the paper I’d found—”Vancomycin Hypersensitivity Reaction Presenting with Extensive Oral Ulcerations.” The mechanism? A Type IV hypersensitivity reaction. Time course? Variable, days to weeks after starting Vancomycin. Other associated conditions? Profound neutropenia.
Finally, I could rest easy, as did our patient when we explained the following morning why his ulcers had occurred and how they would heal in time.
Directions to live by
As we work to help both learners and patients navigate diagnostic pitfalls, I’d like to offer three rules of thumb that have helped me time and again. From a young age, children are taught to “Stop, Look, and Listen” when crossing the street. Clinicians would do well to live by these words in the realm of clinical reasoning:
–Perform a “diagnostic time out” when things get fast and furious.
-Slow it down and consider what questions you may not have given yourself time to ask.
-Does what we observe fit or add to the background of data we’ve been given so far?
-Mind the diagnostic gap, the space between working diagnosis and final destination.
-Stay grounded. Don’t accidentally touch the third rail (consider “Do Not Miss” diagnoses).
–Hearing is passive. We can only listen to something intentionally. Search for the signal amidst the noise.
-Above all else, remember Osler’s words:
“Listen to your patient, (s)he is telling you the diagnosis.”
In the case of our patient, not only was he trying to tell us his diagnosis, it was on the tip of his tongue! By hearing and researching the How of what he felt, we came to understand the Why.
As you continue on your own diagnostic journey, always ask yourself, is this signal or is it noise?