Disclaimer
This article and the related comments are for educational and discussion purposes. They do not establish the standard of care in every patient’s situation. In each patient’s situation, the treating physician or other medical professionals must exercise their professional judgment. Similarly, these materials are not medical advice to patients, who must consult with their own physician or other medical professional.
Patients present inconveniently. Not only do they come in to the hospital at all hours of the day and night, but they may come in with symptoms that don’t suggest an immediate diagnosis. Clinicians (and nurses) have variable degrees of comfort with uncertainty, and let’s face it, when our health is at stake, we all want certainty. Good strategies to cope with uncertainty include taking a great history, not just reviewing someone else’s history. Elicited history adds more knowledge of the patient, and the additional details obtained could be the difference between making a diagnosis early, or not, and sometimes with severe consequences. A great physical exam can discover a lot about a patient and may direct care to order a test to confirm a diagnosis that might otherwise have eluded the clinician. In short, we fall back on our training. We can’t count on rising to the occasion.
To quote myself, “uncertainty is good when things are uncertain.” Clinicians need a special approach for these patients, who represent about 25% of patients we admit. There are some conditions, spinal cord compression is one of them, that can present subtly, and over time declare itself in bits and pieces as additional history, new symptoms, and new physical exam findings. The price of later diagnosis can mean a wheelchair for the rest of a patient’s life. No one person can collect the information as it comes in over time and space. The day nurse, the night nurse, the night doc, the day doc, the APP, the therapist, all are likely to receive information (history, changing symptoms, new physical findings) concerning this patient.
It is impossible for one person to be all knowing and everywhere at once, but it is possible to make the diagnosis of disease that presents subtly. Subtle disease demands teamwork. I call it “the medical necessity of the team.” Certain conditions, like spinal cord compression, sepsis, chest pain and others require contributions from everyone, in accordance with their role. Docs need to acknowledge uncertainty while creating a list of possibilities for what the diagnosis could be, and sharing what the plan is to get to a diagnosis. Nurses need to know what particular symptoms or changes in physical findings suggest alternative diagnoses. Questions will arise, and they should be asked without hesitation. APPS whether working at night or admitting in the day, must accept uncertainty, and then apply themselves in digging into the case to obtain more information.
Of course, teamwork is not just for the harder diagnoses, but for all situations and diagnoses in which the patient is the only constant. We go off shift, off service, have distractions galore, lots of noise, and very faint signal. Subtle diagnoses are an easy way to see the necessity of teams in which everyone has a valuable role and all must speak up. The disease demands teamwork. Uncertainty is not good or bad- and is certainly not a sign of bad doctoring. We dismiss, or explain away uncertainty at the patient’s peril.
Make your team stronger because the medicine demands it. While including the patient, use your training, listen, teach, dig. You will be amazed as subtle becomes clear, uncertain becomes certain, and a group of caring, trained professionals becomes a team.
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