‘Through a glass'
I read the most recent Mindful Medicine column (“Seeing the whole diagnostic picture,” ACP Internist, April 2010) with great interest. I was taught the principle/pitfall of “through a glass narrowly” years ago at Washington University School of Medicine in St. Louis. I used “The Blindmen and the Elephant” just this week while teaching my advanced cardiac life support course for experienced providers. Our scalar (flat) 12-lead electrocardiogram is a two-dimensional representation of the heart (a three-dimensional object). The 12 leads represent different electrocardiographic-geometric views of the heart's varying aspects, just as the blindmen of Hindustan sampled by touch varying aspects of the elephant. The principles of anchoring and availability are ones to guard against in all areas of medicine.
I enjoyed reading the fine observations by Drs. Groopman and Hartzband in “Seeing the whole diagnostic picture.” As I started to read I kept my mind working on what the diagnostic possibilities would be in the patient described. I made notes as I read, listing the differential diagnoses and trying to keep the list as short as possible. With the patient being only 24 years of age, there were only a few things that could be afflicting her. Some type of inflammatory bowel disease, lymphoma or an eating disorder were what kept coming to my mind.
Sending a young female to a pulmonologist at the very outset for the complaint of chest pain was unnecessary and premature. As for treating a possible urinary tract infection with antibiotics at the second ER visit, it was probably based on a urinalysis and not a culture. Another round of antibiotics for presumed pelvic inflammatory disease was again an example of losing focus.
What kept recurring in my mind from the very beginning was the patient's steady weight loss, and this should raise concerns given she was so young. This has to be tied to her persistent abdominal pain, and there must be a relationship. None of the conditions thought of so far would be associated with weight loss. I was surprised to read that the gastroenterologist did an upper rather than a lower endoscopy because her symptoms were more colonic or of the terminal ileum than the stomach. The latter is usually associated with nausea or vomiting, or both.
When the internist with broad knowledge and attention to detail came into the picture, the entire constellation of symptoms was put into perspective and the diagnostic confirmation took the straight, short route. While I was in training, I was told by one of my teachers that when a physician matures he/she will learn that laboratory tests and even a physical examination pale in importance compared with a good history, so much so that if a physician listens well to his patient, the patient may well be giving the diagnosis.