D.P. – What It Is Is (But Sometimes It Ain’t)
Dr. Dee had a patient with appendicitis who had pain on the left side instead of the right. He did a fine job ’cause he did not succumb to diagnostic perseveration, or D.P.
D.P. is a common error, and one that is easy to fall into. In it, you hold onto your original hypothesis at all costs. At first for all the world the patient seemed to have diverticulitis, but after a couple days it didn’t add up, and Dr. D reversed field and considered appendicitis. A CT confirmed the suspicion, and the patient did well.
In medicine what is is most of the time, but one has to keep in mind what is sometimes ain’t. At times folks don’t understand, but it is why we are very reluctant to ever assume much or diagnose over the telephone. Nothing strikes fear in me more than to have someone call and say, “well, I’m ‘pretty sure’ I have a stomach virus.” (One time when it turns out to be an aneurysm will make a believer out of you right quick.)
Knock on wood; tomorrow might be the day I have a disaster, but I have been saved more than once by not falling into diagnostic perseveration. Most of the time, I got it right ’cause I came, I saw, and I reconsidered a few times in the interview. Often it is because the patient gave me the clues that made me chunk my original theory about what was wrong.
There is an old saying in medicine: “If all else fails, ask the patient. (like reading the directions, I guess) They will usually tell you what is wrong.” That has proved true over and over for me. They might not say “I think I have scleroderma,” but they will sure enough tell you the symptoms that will lead you down the right path if you don’t forget to listen.
For Dr. Dee’s patient, it is a good thing he listened. What it is is, but it wasn’t. Thank goodness his radar was up and he was not bitten by D.P. The patient was happy about it too.
Dr. B
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June 7, 2008 at 9:29 am
Its funny, reading today’s post I couldn’t help but relate it to my own field – computers. Many times in computer programming, and repair, things that are SUPPOSED to work one way work just the opposite, even though logic tells you otherwise. You have to be flexible enough to think “outside the box”. Otherwise, you will never get the solution to the problem.
There are computer manuals, but alas, the person writing them hasn’t actually seen EVERY problem and instance that can arrise. For that you have to rely on your own wit and skill. Sometimes dumb luck.
Good post Doc.
June 7, 2008 at 9:41 am
Ms Amber,
Luck can come into play. One time I ordered a thyroid test on the wrong patient and the result was very low! I repeated it to be sure and it was true. (The other patient was O.K.!)
They thought I was brilliant. I told them I ordered it by accident but I don’t think they believed me. Oh well.
Dr. B
June 7, 2008 at 9:45 am
Some times we have to trust what we feel and not what we know. That old saying about looking like a duck is not always true!
June 7, 2008 at 10:39 am
ms. Cindy
In medicine the one they use is “if you hear hoofbeats think horses, not zebras. You have to careful, though. Them rascals’ll stripe you very so often.
Dr. B
June 9, 2008 at 7:20 am
Listening is one of the most important of all human relations skills. Until recently, I don’t think it was taught in med school. Is this still the case, or have programs begun teaching active listening as a learnable skill? – Ted
June 9, 2008 at 7:57 am
Ted,
When I went to med school the norm was to only listen to the Professors! However, I will brag on Sandhills- I think they got on the idea of the importance of listening to patients earlier than most.
From what I can gather from med students who come through and from my journals, this has improved.
Dr. B