My story isn't Serena Williams' story, but some things sound the same

Grubenhoff, Joe Joe.Grubenhoff at CHILDRENSCOLORADO.ORG
Tue Aug 21 17:22:00 UTC 2018


It seems that a reasonable number of DDx points is dependent on the presenting complaint, history and exam findings and the patient’s degree of illness. An example may help elucidate my thoughts.

Case 1: 1 day Acute onset of stridor and barky cough in a 2 year old child wo vomiting, diarrhea, lip/tongue swelling.  T 38.0, RR 56, HR 168, Sats 94% RA, mild inspiratory stridor at rest on exam, minimal distress, clear lungs, no limitations in neck ROM, no rash – this is very likely infectious but need to consider exploratory behavior.
                DDx: CROUP (most likely), Epiglottitis (can’t miss dx), FB aspiration  (we can discuss until blue in face about more esoteric/rare or less well supported things that could go on Ddx)

Case 2: 5 day history of progressively worsening stridor, barky cough, ill appearance, fevers to 39. T 40.1, RR 56, HR 168, Sats 90% RA, ins/exp stridor, rare crackles on exam, moderate distress, ROM limited, ill appearing, no rash
                DDx: bacterial tracheitis, (recalcitrant) croup say from FluA, epiglottitis, vascular ring/sling with obstruction leading to pneumonia, retropharyngeal abscess, mediastinal mass.

Point is, it may be arbitrary to say exactly how many points should be on an initial DDx. I watch our residents in Morning Report list a dozen or more conditions because a patient has 1 or 2 symptoms/signs of a particular disease but in which the illness script otherwise is a poor match. If we are concerned about overdiagnosis, we need to be cautious about how we employ dictums as to how many diagnoses to consider.

One of my best teachers (James Todd of toxic shock syndrome fame), said “Think about what will quickly kill the patient, what’s most common, and what’s going around.” In other words, have a strategy to developing the Ddx.

jg

From: Edward Winslow <edbjwinslow at GMAIL.COM>
Reply-To: Society Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Edward Winslow <edbjwinslow at GMAIL.COM>
Date: Tuesday, August 21, 2018 at 09:36
To: Society Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] My story isn't Serena Williams' story, but some things sound the same

I absolutely agree with Jason!!

Including several other things that might be responsible for at least some of the patient's complaints is a potential sibliminal technique to help avoid "confirmation bias". As long as there is a DD (sometimes by the younger generation referred to as "Rule Outs" - a topic for another note), clinicians are encouraged to look beyond their "Initial Impression". I am a little surprised that Jason is asking for FIVE DD points. I used to insist on three. It would be of interest to ask members of this board, "How many DD considerations do you believe is appropriate?"

I, also, do like the suggestion that we include as part of the DD, the "patient's suspicion". I must point out, though, that when I ask patients what they think might be the explanation for their complaints, they often, indignantly, point out that they are there for me to tell them. How to keep this from getting in the way of the physician-patient relationship is something that we must be aware of.

Ted

On Tue, Aug 21, 2018 at 4:29 AM, Jason Maude <jason.maude at isabelhealthcare.com<mailto:jason.maude at isabelhealthcare.com>> wrote:
Agree, it’s baffling in these cases why the clinicians seem so reluctant to listen. As one doctor wrote recently in an article, why would you not add the patient’s suggestions into your differential?

My thoughts on this have always been that institutions should require clinicians to record their differential in the medical notes.

We have heard of recently of one that requires a differential to be recorded and contain at least 5 diagnoses. I would extend this to add another box which records both how the patient described their own symptoms (in their own words) and also any diagnoses they were concerned about. When these things are recorded early on then behaviour will change.

Regards
Jason

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890
www.isabelhealthcare.com<http://www.isabelhealthcare.com/>

From: HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>>
Date: Tuesday, 21 August 2018 at 02:07
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] My story isn't Serena Williams' story, but some things sound the same

Excellent personal article from a doctor-turned-patient about implicit bias in medical decision-making. What can WE at SIDM suggest to doctors to change this common error?
https://www.kevinmd.com/blog/2018/08/my-story-isnt-serena-williams-story-but-some-things-sound-the-same.html
Best,
Helene

My story isn’t Serena Williams’ story, but some things sound the same

Diana Cejas, MD<https://www.kevinmd.com/blog/post-author/diana-cejas> Conditions<https://www.kevinmd.com/blog/category/conditions> August 16, 2018

I’m not much of a tennis fan, but I am a fan of Serena Williams. Who wouldn’t be after hearing her story? Her rise to the upper echelon of athletics was remarkable, and her longevity is incomparable. All the while, she has challenged the sporting world’s notions about who and what an elite tennis player is supposed to be. I watched her interviews after this year’s Wimbledon finals and was once again in awe.

Less than a year prior to this championship, Ms. Williams delivered a baby girl and then suffered from a pulmonary embolism and other complications. What stuck with me most about her delivery story was the fact that her doctors didn’t seem to take her at her word. Ms. Williams has a history of a previous pulmonary embolism and knew the signs, symptoms, and management. When she became short of breath, she voiced her concerns about the possibility of a pulmonary embolism and asked to be worked up for it. However, members of her health care team thought that she was confused and tried to calm her down. They didn’t seem to believe her. They acquiesced after she kept insisting. What would have happened if she hadn’t kept insisting? Why didn’t they believe her the first time she said that something was wrong?

I need my doctors to believe me. I am quite sensitive about that, and that is because I know what it feels like when they don’t. I found a mass on the right side of my neck during my first year of medical school. I remember pointing it out to my friends after anatomy lab and all of us agreeing that I should have it checked out. I dutifully went to student health where I was told that the mass was a lymph node and that I shouldn’t worry about it.

Even then, I knew that didn’t seem right. I went back to student health and other doctors again and again as the mass slowly grew. Each time I was told it was some kind of lymphadenopathy or a random infection and something not worth troubling myself about. I asked for imaging and was denied over and over again. By the time I was a second-year resident, the walnut-sized mass was hard and fixed in place with three rubbery lymph nodes on top of it. I knew. I went to another doctor, and when she started to tell me not to worry about it, I had what amounted to a hissy fit. I knew myself and my body. I knew something wasn’t right and I wanted imaging.

She ordered a CT to appease me, and I had it done that same day. Within two hours, I had my diagnosis: carotid body paraganglioma. It was resected, and those three lymph nodes were sent to pathology. That’s when it was confirmed to be malignant.

Cancer and the stroke that followed it changed my whole life. It upended everything I thought I knew about the doctor-patient relationship. I realize that I had a relatively rare cancer and that my outcomes were unexpected. I could understand my physicians’ reassurance after our first meetings. I was young and otherwise healthy. Nothing was supposed to go wrong. What I couldn’t understand is that I kept coming back with the same complaint, a growing concern, and a growing mass, and despite that, my concerns were continually dismissed. I was a medical student and then a doctor myself and still felt like no one took me seriously. I started to wonder why.

A growing number of studies are examining the way that physicians respond to their patient’s complaints. Too often, it seems that physicians downplay their patients’ pain, psychiatric symptoms, trauma and other concerning issues. Implicit biases and other psychosocial factors certainly influence our interactions with patients. Women, people with disabilities, minorities and other members of marginalized communities are particularly vulnerable to bias within the medical community.

Unfortunately, these biases lead to poor patient outcomes. We, physicians, know that these disparities exist but we seem to be a bit unwilling to question ourselves about them. How often have we heard patients complain that doctors don’t listen to them? That we don’t take our patients seriously? How often are these patients labeled as “difficult,” “noncompliant” or “crazy?” How often are those patients women? Black? Latino? Gay? How often do those patients look different from us?

My story isn’t Serena Williams’ story, but some things sound the same.

We’re both young black women in positions of privilege who faced a catastrophic illness. Despite our respective privileges, we both had to fight to get the health care that we needed. Things could have been worse for us both, but they could have been a lot better too. I wonder if things would have been different if my first doctor had ordered a CT scan. I wonder if the tumor would have had the time to spread. I wonder if I would have had a stroke. Regardless of how things turned out, I’m glad for the lessons that I’ve learned. I know now that listening to my patients and making them feel heard is one of the most important things that I can do for them.

Sometimes a patient’s complaints seem outlandish and their symptoms impossible. But sometimes they’re right. Sometimes just listening to a patient can save their life.

Diana Cejas is a pediatric neurologist.

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