Reviving Case Reports: Chasing Zebras or Solving Mysteries?

31 08 2010

I am teaching a new course this week entitled “Turning your Clinical Cases into Scholarly Work.”  I hope to draw on my own experiences through the years mentoring students and residents in writing up several clinical cases, but also in making diagnoses.  In preparing for this course, I have also learned quite a bit about the controversy surrounding case reports and the challenges that they face in today’s healthcare system. 

Unfortunately, case reports have fallen out of vogue.  Many journals no longer accept case reports or they have relegated them to the 2nd class ‘online’ only publication since they are often not highly cited and lead to a lower journal impact factor.  Critics of case reports actually say they overemphasize the unusual at the expense of the ordinary and are not evidence-based.  Furthermore, in today’s era of cost consciousness medicine, chasing ‘zebras’ or unique diagnosis is often frowned upon due to the potential for inappropriate or overuse of tests, with the possible unintended consequences of working up incidentilomas

Despite these concerns, case reports have had a major impact on the discovery of new diseases, mechanisms of disease and even drug therapies.  The first cases of AIDS were reported as case reports.  Side effects of drugs are often discovered through case reports and can lead to changes clinical practice (MRI contrast and nephrogenic systemic fibrosis) to prevent harm.  Cases reporting potentially desired side effects can also prompt accidental discovery of new drugs that can change quality of life for many people, as is the case with Viagra

So, how can we promote the art of case reports without creating zebra chasers who drive up healthcare costs?  Well, the key may lie in Sherlock Holmes.  Medicine is often compared to detective work and it is well known that Sherlock Holmes used the power of observation to make informed deduction.  While Holmes was a fictional character, the invention of Sir Arthur Conan Doyle (a doctor turned writer), he was modeled after Dr. Joseph Bell, Doyle’s former physician-mentor.  To get his trainees interested in observation, Dr. Bell used the power of observation to deduce mundane things like occupation and recent activity in passersby.  In essence, the clues to making the diagnosis lie in careful understanding of the patient’s story and observation of the physical cues.    

Unfortunately, the powers of observation are declining these days due to the ease of ordering CT scans without thinking about a patient.  Fear of malpractice also drives the use of diagnostic testing over trusting one’s self.  To make matters worse, diagnostic tests are financially rewarded, while thinking about the right test to order to make the diagnosis is not.  If the art of diagnosis were more handsomely rewarded, more hospitals would actually have a “Department of Diagnostic Medicine” led by their own version of Dr. House (who is based on Holmes incidentally …and Chasing Zebras was considered as a title of the show).  As stated by Rapezzi and colleagues…

Current trend towards mass use of sophisticated diagnostic tools in routine practice—accompanied by a blind faith in technology and predefined diagnostic algorithms—is threatening to kill off the science and art of clinical reasoning. Besides burning a lot of public and private money to make diagnostic work rather superficial, doctors also risk losing the intellectual pleasure that comes from careful diagnostic reasoning.

So, in considering how to revive case reports and the art of diagnosis, its worth revisiting lessons dating back to the old adages that been used to teach generations of doctors before the proliferation of imaging.  While each of these rules has its faults, they represent a return to thinking about the diagnosis.   If only it was only as simple as, “It’s elementary, my dear Watson”…   

Occam’s Razor – “entities must not be multiplied beyond necessity” refers to the thought there is usually one unifying diagnosis.  The term razor is used to highlight shaving away unnecessary assumptions to get to simplest explanation. 

Hickam’s dictum – “Patients can have as many diseases as they well please” The counterfactual to Occam’s razor is credited to John Hickam, MD who highlights that it is statistically more likely for a patient to have several common diseases explaining a constellation of symptoms rather than a rare zebra.  The best example of this is Saint’s triad which consists of gallstones, hiatal hernia, and diverticulosis which don’t have anything to do with each other other than they are often common in patients.

Pasteur’s dictum  – ‘chance favors only the prepared mind’  This refers to the fact that to make the ‘leap’ of discovery, one must have the knowledge & skills to be able to make the connection.  In other words, you cannot find an interesting case if you are not reading and know what to look for.

Sutton’s law- First, consider the obvious.  In other words, conduct the test which will confirm (or rule out) the most likely diagnosis.  This phrase is named for bank robber Willie Sutton, who when asked why he robbed banks supposedly answered “because that’s where the money is.”





Attending Rounds with the iPad – Hype or Hindrance?

12 08 2010

I recently completed a two week tour of duty on the wards in July with new residents, interns, and students.  Attending (serving as the supervising doctor for the team of residents, interns and students) in July can be challenging, but also one of the most rewarding clinical experiences as a faculty member.  The interns and residents are eager to learn and your teaching may have a more lasting impact as the residents and students are just forming the habits that will become the foundation of their clinical practice.  Over the last six years, I actually request to be on service in July for this reason.  Despite all the recent concern about the ‘July effect’, attendings are often hovering closer and more involved in patient care than in other months.  This July, I also took that opportunity to test the iPad on the wards to experience firsthand how it stacked up. 

Well, it certainly lived up to the hype!  Here are some of the powerful examples of what I was able to do with the iPad while I was on service.

  • Point of Care Teaching –On rounds, I was able to use MedCalc to show my team and calculate Ranson’s criteria for a pancreatitis patient, the San Francisco syncope score on a patient in the ER, and to correct the sodium (pseudohyponatremia) for a patient presenting with DKA.  I also used UpToDate (institutional subscription) to review the ARA criteria for lupus and rheumatoid arthritis for patients with these conditions.  (of course I did not do this on post-call days when the clock was ticking). 
  • Preparing for Teaching Rounds – At home in the evening, I could look up an article that was relevant to a specific patient and bookmark it on the iPad.  Then, the next day, instead of wasting paper and time on the time-honored tradition of photocopying articles before rounds, I could pull up the bookmark for community-acquired pneumonia and show the team the relevant graphic or passage in a paper.  Then, with one quick stroke, I could email the team so they had the link to review later that day.    
  • Immediate Access to a Computer – One morning, I found all the workstations occupied and I needed to text page my team.  From the hall, I simply opened my iPad and used the ‘shortlink’ to the paging system to let my residents know where I was.  Likewise, at a multidisciplinary case management rounds, I made use of the time waiting my turn by completing my billing through using the STAT-ICD9 coder app.  I also looked up narcotic dosing in Epocrates for a patient’s prescription (in Illinois only physicians with permanent licenses can write narcotic prescriptions in case you’re wondering).
  • Access to the medical record  – Our hospital uses Epic, so using the Citrix iPad client, I could access the medical record from anywhere on the hospital wireless.  However, the Epic interface is often clumsy if you don’t have tiny fingers making me wonder what my male counterparts would do!  We’re currently working on getting a stylus to try to improve use of Epic.  
  • Stay in touch with my team throughout the day –In the middle of a late afternoon workshop that I teach in, I was listening to a presentation when I got a text page. I just opened the link to our paging system to answer the question which averted the need to go hunt for an open phone.
  • Balancing clinical work with your academic work – Unfortunately, email for an academic physician does not stop when you’re on service… it just accumulates, resulting in stress and delay.  With the iPad, I stayed on top of my inbox while walking to and from the wards or during idle time on the wards waiting for my team or for patients to return from tests.  My research project manager also noted that I was not as behind on her emails.  In today’s email game, anything to improve your email is worth it!
  • Leisure and relaxation – For any healthcare worker, relaxation to unwind and be well rested for the next day is key.  When I got home from work, my iPad turned into the quintessential leisure tool.  I could use Flipboard to catch up on my Facebook friends or Twitterfeed that I missed through the day.  I could catch up on news ranging from the latest in the Gulf oil spill to Lindsay’s jail sentence so that I did not feel like was in ‘the fog of wards’.  I also used UrbanSpoon to find a restaurant for our off-service dinner and then Maps to figure out how to get there.

However, before we embrace the iPad as the panacea to all of our technology woes in healthcare, there are some hindrances that we need to think about.   

  • Security – Unlike my trusty clipboard, you cannot leave your iPad on the workstation or counter as you go into the room.  Then, when you go into the room, it’s a challenge finding a location for it while you examine patients.  For this reason, I did not carry the iPad with me every day and only used it on days that I knew I wasn’t going to be overwhelmed with new admissions.  Contrary to this post, the iPad does not fit in our white coats.  After some thought (including buying new coats), the most ideal solution was to use a shoulder strap.  My personal favorite is a fashionable tan leather stitching that was on overstock.com.  Now, I can take my iPad with me every day. 
  • Infection risk – As one tweeter put it, will your iPad (or iPhone) become the iGerm?  It is important to use a disinfectant to keep the iPad clean.  After a few days on the wards, my iPad was covered with fingerprints carrying who knows what… so I wiped it down with some disinfectant cleaner and it looked new and shiny again.  The shoulder strap also works here since I would wear the iPad and put on my contact isolation gown on over the iPad keeping it protected.
  • Multiple windows – Currently, the iPad does not have the ability to have multiple windows open.  This is the most disabling feature of the iPad.  If you are in medical record, you have to log back in if you decide to access UpToDate.  While you could access all of the hospital intranet on the Citrix client, it is slower than the iPad’s native apps and not as nice. 
  • Wireless access – Fortunately, our hospital has a very good network.  Unfortunately, it does not work in all areas of the hospital (my office, spotty in stairwells) and sometimes I have to switch to the University wireless which requires a log in each time I access it which can be somewhat challenging.   

While this is my n of 1 experience, we are currently piloting the iPad with 5 residents to ascertain its value as a point of care clinical and educational tool.  We provided the residents with fully loaded iPads with a variety of apps for our residents to test.  Apparently, we are not the only ones with this idea.  Last week, Stanford University School of Medicine announced that every entering student would receive an iPad.  Time for iMedSchool & iResidency?                                                                            

-Vineet Arora MD








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