I hope I can word this so that makes sense.
In what manner do you learn to diagnose what is wrong with a patient? I’m finishing up an EMT class and we basically have to memorize common situations we see in the field with their signs and symptoms. The problem with this is there are thousands of diseases, or failing/injured organs and systems, which share the same signs and symptoms and we don’t really get any kind of an understanding about them except emergency care for the short trip to the hospital. As I think about all of the troubles our bodies can run into, I can’t imagine how you can memorize diseases and their signs and symptoms then be expected to come up with a diagnosis.
So, in medical school, do you learn about the body systems and how they act when they fail or are injured, and then onto an understanding of the way diseases interact with humanoids making it more of an understanding instead of complete rote memorization? 
I hope this question makes sense 
Since I’m not a physician, and my field of practice doesn’t encompass NEAR as much, I can give you a little info as to how I “diagnose” speech and language issues.
Basically it’s a series of question/answer/deduction with my clients and observing behavior. We are taught the basic etiology and symptoms of the most common issues (e.g. CVA - dysphagia, aphasia (of which there are many types), apraxia and so on…).
You will learn to identify which symptoms, complaints, and behaviors go with what, and what the results of diagnostic testing based on your suspicions are.
I’m sure the docs on here can explain better, but I at least wanted to put my .02 in there.
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I hope I can word this so that makes sense.
In what manner do you learn to diagnose what is wrong with a patient? I’m finishing up an EMT class and we basically have to memorize common situations we see in the field with their signs and symptoms. The problem with this is there are thousands of diseases, or failing/injured organs and systems, which share the same signs and symptoms and we don’t really get any kind of an understanding about them except emergency care for the short trip to the hospital. As I think about all of the troubles our bodies can run into, I can’t imagine how you can memorize diseases and their signs and symptoms then be expected to come up with a diagnosis.
So, in medical school, do you learn about the body systems and how they act when they fail or are injured, and then onto an understanding of the way diseases interact with humanoids making it more of an understanding instead of complete rote memorization?
I hope this question makes sense
Now you understand a little better about Medicine and Diagnoses.
We learn the Signs and Symptoms and what makes one condition the Diagnoses verses the othe condition, there are Key symptoms, “Pearls” and “Hallmarks” of diseases point the way to diagnoses but sometimes Signs and symptoms gives us something to rule out then we need other tests to back up our suspicion of what it is.
Sometimes its easy and others it takes a lot of tests to narrow it down, you learn this through out Medschool and clinical rotation through residency, and on through practice it does take a long time, I look at it as puzzles when all the pieces fit the diagnoses is made.
Unlike an EMT, a doctor generally has time to ponder, tests to run, and–most especially–things to look up. You can’t remember everything.
But, here’s one way this pathway might go. Let’s say you as an EMT arrive at the scene and someone is groggily coming to; a bystander says, “they just kind of fell down on the ground.” Now, as an EMT you know some questions to ask–were they convulsing? do they have bowel or bladder contents in their pants? (signs of seizure) do they have a traumatic injury from the fall? are their vital signs stable? Are they in pain?
As an EMT you might be thinking about seizure versus aortic dissection versus a stroke–the stuff that, if you increase your suspicion one way or another, would change your management on the way into the ED and might even dictate what ED you go to. Right? (I’ve never been an EMT, so I don’t know!)
Now, the person comes into the ED. Here’s where the doctors come in. They start with the same “What’s going to kill him?/what do we have to do something about right now?” questions that you do.
Then doctors (and medical students!) start trying to put the whole history together in more detail. We ask the patient questions: What does he remember? What does he think happened? Has this ever happened before? And we look for physical signs, for things like how the person fell. Did they hit their head first, or did they defend the fall by putting out their arms and hands? That’s another branch point–it suggests answers to questions like, did the person lose consciousness suddenly, did they fade to black, and did they pass out before they fell or pass out because they fell and hit their head? (The latter starts heading down a head trauma pathway first and foremost and then thinking about why they fell after that; for the person who put their hands out and has abrasions on their palms and forearms and no sign of hitting their head, the head trauma workup is farther down our list of priorities, and we might be much more worried about their heart. In both cases, we’re keeping both possibilities in mind–but we’re also guided by probabilities.)
None of this is about memorizing diagnoses–it’s about thinking through, what are all the things that contribute to consciousness and standing upright, and what might have gone wrong? Then you start trying to think through, what can I find out that will make me think one thing is more likely than another?
So, let’s take one branch point: the person faded out, kind of crumpled onto her desk at work, was alert and oriented right after waking up.
OK, so this sounds like a failure of oxygen delivery to the brain. In that case, it might be the heart–a failure to put blood forward to the head. There’s an EKG almost as soon as the person shows up–if there’s an obvious arrythmia or ST elevations, you’ve got your likely pathway right there. You employ your EKG techniques for the basics; you consider calling in a cardiology consult and/or looking stuff up for what you can’t make sense of. (Looking at an EKG, you ask yourself, is this little extended interval associated with other sudden-onset arrythmias? You can’t remember, so you go look it up.) You could have some big and sudden lung problem–you make sure that you’ve done a lung exam and you’ve got a chest X-ray.
It might also be just not enough blood–you could pass out from being anemic. That’s why you got a complete blood count as soon as she rolled in–in fact, the CBC results are at the top of several important branch points, so the nurse may have sent it as a matter of course without you even writing an order first.
This goes on and on. A syncope workup causes you to think about heart, blood, lungs, brain (both neurologic and psychiatric), and musculoskeletal issues. The differential is huge. But the history and physical and then initial screening test results (CBC, EKG, chest X-ray) start guiding you towards one system or another, and away from half or three-quarters of that differential almost as soon as you start. (I should emphasize that, as one of my professors told me, 75% of this is about taking a good history. At least.)
Once you sort the information into particular organ systems, your differential becomes more fine-tuned.
Let me give an example of how you actually learn these things as a med student. Based on what I know off-hand, I say, OK: heart–could be a valve problem, could be a vessel problem (coronary artery occlusion causing an MI, or an aortic dissection), could be an arrythmia. This is the big obvious stuff. Except–wait–is that it?
I try to stretch the point, again just thinking through how the heart works. I ask myself, hey, what about the muscle–could a cardiomyopathy in and of itself cause these symptoms? (Separate from it increasing the likelihood of arrythmias or MI, that is.) I should know this, but I don’t, so I go look that up. (I’m actually doing this as I write this edited version of the post.) I go to Up-to-Date, my usual first-line electronic reference; the article about syncope doesn’t mention cardiomyopathy in and of itself in the text, and other than thinking about underlying pathology that might be contributing to the valve, vessel or electric problems, I think for a second, well, maybe that’s not a big part of this workup.
Then I rethink–wait a second, that’s not right–I think vaguely of something, and look up “cardiomyopathy”–of course! sudden cardiac death! Then I see something in the sudden cardiac death article about hypertrophic cardiomyopathy, which is common (“How stupid am I? How could I forget that?” I ask myself, a non-productive habit of mine) and then also see something about arrythmogenic right ventricular dysplasia; crap, I think, I’m not sure I’ve even heard of that. (Brief look at that section–more common in Italy than the US. Huh? Well, I’ll look that up later.) And dilated cardiomyopathy! Arrythmias and sudden death. Right. Well, I was covering the question of arrythmias in a different part of my differential, but I wasn’t thinking about muscle very much. Huh, I think. I can’t believe how much I’ve already learned and forgotten.
(And what’s with that syncope article, anyway? It led me astray! I go back–did I miss something? Oh crap, I should’ve clicked through to that big table of “common causes”–there’s hypertrophic cardiomyopathy right there.)
OK, I think, after this, I will definitely be remembering that heart muscle is part of what I need to be thinking about in this part of the differential–and hopefully I’ll remember the particular diagnoses. If I don’t, I’ll remember them better when I repeat this process again in three months, and in my residency, and so on. Not only that, but now I also stumbled into remembering that there’s a difference between syncope and cardiac arrest in conceptual terms–that one can foretell the likelihood of the other, but that it’s important to separate them.
If I were in the hospital, then in the time it takes to look up all of that stuff after the quick initial workup, the cardiac enzymes have come back, we’ve got a formal read on the X-ray from radiology, I’ve been looking at the telemetry monitor every so often, and we’re ready to take the next step. I realize that this is part of what we were thinking about when we looked at the axis on the EKG–riiiiight, I think, left axis deviation–and realize that the patient’s EKG was totally normal. OK, it probably isn’t hypertrophic cardiomyopathy.
Then I get a bit of time later and look up hypertrophic cardiomyopathy. OK, now I have to remember, how does it cause syncope and sudden cardiac death? That’s another story, but I’m a bit reassured because I think that I’ve covered all those manifestations of HCM in other parts of my exam. OK, I’m not a total screw up–but in the twenty minutes it’s taken me to write this, I’ve become a better doctor.
And there are years of this, doing this every da
y.
I don’t think you memorize these differentials exactly, or at least I’m not very good at that–you come to know them because you think about, what is a heart? what goes wrong with a heart?
You also do start to memorize these pathways, once you go down them a bunch of times. But they are easier to memorize when you go organ system by organ system.
I think this never stops being hard; but, the parts that are hard will be more and more advanced as you go on. In other words, you will never stop feeling frustrated sometimes, and you will never stop getting better and better at it.
joe
Forget it. Deleted
Rereading my post, I realize I didn’t know any of this before medical school. I probably couldn’t have even understood this post. That is pleasing to realize for myself, but perhaps it is completely useless in answering your question. I hope you can cut through the jargon to see the places where I’m talking about the process–as you get more training in pathophysiology, you do things more via a process than through rote lists, and that is the much simpler but quite similar answer to your question.
joe
Thanks to everyone who responded.
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as you get more training in pathophysiology, you do things more via a process than through rote lists,
joe
That’s what I got from your post. I was starting to get concerned because I like to know the “why” as much as the “what” so those concerns can be laid to rest.
Thank you
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Unlike an EMT, a doctor generally has time to ponder, tests to run, and–most especially–things to look up. You can’t remember everything.
But, here’s one way this pathway might go. Let’s say you as an EMT arrive at the scene and someone is groggily coming to; a bystander says, “they just kind of fell down on the ground.” Now, as an EMT you know some questions to ask–were they convulsing? do they have bowel or bladder contents in their pants? (signs of seizure) do they have a traumatic injury from the fall? are their vital signs stable? Are they in pain?
This is one of the most fascinating posts I’ve EVER seen on OPM. PHENOMINAL!!!
It’s also such a cool reminder of why graduate training seems so valuable to being a physician since as a scientist you have to methodically establish a hypothesis, design experiments to test it, test it, then analyze your results.
I don’t think I’d ever really put MD/PhD training in this perspective before and it a good reminder than I’m not insane for having this goal at 39 years old!
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Thanks to everyone who responded.Quote:
as you get more training in pathophysiology, you do things more via a process than through rote lists,
joe
That’s what I got from your post. I was starting to get concerned because I like to know the “why” as much as the “what” so those concerns can be laid to rest.
Thank you
Hi there,
The biggest emergency situation in any physician’s life is when a patient stops breathing or the heart stops. We treat this situation the same way each time. Airway, Breathing, Circulation, likely the same things that you learn as an EMT. It just does not get any worse than this. Even a patient with a gunshot wound to the chest gets the same treatment: Airway, Breathing and Circulation. Now I might have to open the chest to restore circulation but I guarantee that the ETT will be in place and that ventilation is taking place. That is why Dave earns the big bucks.
When it comes to making a diagnosis, experience is the great teacher. Often as a surgeon, I have to make a decision to operate or not to operate, based on a limited amount of information. My four years of experience has given me some insight into how to go about this process. I have done little memorization since medical school and loads more observation and history-taking. These are the keys to getting the correct diagnosis.
Since there are times when the patient cannot (or will not) give you a history and therefore observation comes in pretty handy. Any person can be a good observer and any person can take the time to ask questions. These are things that you can practice as an EMT. Look at your patients, follow up on them when they are in the hospital to find out what the actual diagnosis was.
You can memorize everything in Harrison’s Internal Medicine and Kumar’s Pathology but be a very poor diagnostician. You can just barely pass everything in first and second year of medical school but be an ace diagnostician because you have good communication skills and good powers of observation.
Use your EMT to practice these things, follow up on your patients and get as much experience as you can. Experience in medicine is always the best teacher. This is why as you become a chief resident (like Mary RR) after you have some experience in residency. As you get that experience on the wards and in the clinics, the differential diagnoses process become less of a mystery and more second-nature.
Good luck!
Natalie
Joe has wonderfully illustrated how this process works. Let me give an example of someone who IMHO wasn’t very good at it: a senior resident I observed during my second ICU month as an intern. The case in question involved a woman who was bleeding internally; by the time she got transferred to the ICU she was intubated, hypothermic, acidotic and unresponsive. In other words, pretty darn close to dying (which happened several hours later). The ABCs had been addressed as well as could be given that she kept bleeding from her esophageal varices despite heroic efforts to stop it.
The senior noted that her potassium was elevated and wanted me to get an EKG. That is because, when someone’s K is up, you get an EKG - it’s a sort of reflexive response. However, in this particular instance, it was the lowest possible nursing priority and wouldn’t have made the least bit of difference in our plan of care. But, but, but … spluttered this resident whose lack of common sense had annoyed me prior to this day … “we need the EKG!” “And what will we DO with the EKG when we get it? How will you change your approach? What will you do differently?” Since I was two years junior to him, he found my questions impertinent but I didn’t care. (he was a jerk)
Anyway, that’s my anecdote about why you DON’T just memorize. Everything needs to be in context.
Mary
Excellent point, Mary. It’s important to use the clinical decision-making skills that (hopefully) you’ve been trained to use.
Joe, what a great explanation. Of course, just in the post it reminded me of all the things I might not have thought about!
Mary, I loved your post. Reminded me of a comparison I once heard about two physicians (attendings actually), by some residents:
Dr. X makes you think about every test you order.
Dr. Y wants you to order every test you think about.
One of things I’ve most appreciated is attendings who let me order stuff (properly countersigned of course!), but who make me explain why I’m ordering them. I learn more. (And I’ve finally started ordering blood counts, not reflexively ordering CBCs, when I really only need what a blood count provides).
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Joe has wonderfully illustrated how this process works. Let me give an example of someone who IMHO wasn’t very good at it: a senior resident I observed during my second ICU month as an intern. The case in question involved a woman who was bleeding internally; by the time she got transferred to the ICU she was intubated, hypothermic, acidotic and unresponsive. In other words, pretty darn close to dying (which happened several hours later). The ABCs had been addressed as well as could be given that she kept bleeding from her esophageal varices despite heroic efforts to stop it.
The senior noted that her potassium was elevated and wanted me to get an EKG. That is because, when someone’s K is up, you get an EKG - it’s a sort of reflexive response. However, in this particular instance, it was the lowest possible nursing priority and wouldn’t have made the least bit of difference in our plan of care. But, but, but … spluttered this resident whose lack of common sense had annoyed me prior to this day … “we need the EKG!” “And what will we DO with the EKG when we get it? How will you change your approach? What will you do differently?” Since I was two years junior to him, he found my questions impertinent but I didn’t care. (he was a jerk)
Anyway, that’s my anecdote about why you DON’T just memorize. Everything needs to be in context.
Mary
Thanks Mary, I was thinking of something like that but couldn’t just put it right! The hordes of info we digest used to make decisions based on critical thinking and outcomes.
Love it!
