Thursday, September 21, 2006

Two diagnoses is the gracious approach

One diagnosis is the ideal of medicine, the most elegant and parsimonious way of explaining patient symptoms and findings. The patient with shortness of breath, pallor, weight loss, and chest pain, for example is not an anorexic asthmatic who snorted cocaine, but a victim of colon cancer, whose disease by chronic occult bleeding caused severe anemia and demand cardiac ischemia. This concept, one of medicine’s most revered principles, is taught to us early in medical education and hounded into our minds thereafter.

Two diagnoses, however, as an attending recently noted on rounds, is the more gracious approach. When a senior team member (i.e. attending) suggests an unusual diagnosis to the team when a more common diagnosis is already known to be active, the tactful resident or fellow will offer that both diagnoses may be contributing. (“Well, we thought the anemia was probably due to her severe iron deficiency, but certainly she could be hemolyzing as well.”)

Put two distinguished attendings on rounds together and you’ll never see so many dual diagnoses, our attending commented.

Of course, if you open your mouth as a medical student, you’ll be shot down before you even know what happened. A favorite teaching tactic of attendings, in fact, is to make you tell them why the diagnosis you just suggested is unlikely (or very unlikely). To prevent such humiliation, most students and residents will preface any proposed diagnosis with one or two reasons why it doesn’t quite fit. Such are the growing pains of medical education, and appropriately so; after all, one diagnosis is the ideal model for medicine. Nonetheless, we can take comfort in the knowledge that some day, when we have reached the necessary level of seniority and respect, we too may be indulged with that second diagnosis.