Ohad Oren on counting symptoms or trusting intuition

Ohad Oren Finding out what’s wrong with a patient is the ultimate challenge for doctors, and relies on a multitude of factors. The other day I encountered an enigmatic patient. He arrived on the ward with a mild fever, abdominal pain and fatigue.

His loss of appetite was obvious from the lunch he couldn’t finish; but this observation seemed trivial in a musclebound, recently discharged battalion-combat soldier. He reported only a viral infection three weeks before admission. This did not give me any vital clues as to his current frailty.

Palpable in my pocket was a reflex hammer. The words of a cardiology expert rang in my mind: “Enhanced tendon reflexes are a possible manifestation of a neoplastic disease, always keep in mind!” I felt torn between scrutinising the patient’s past respiratory tract infection and delving into his occupation (he was a barman), along with the unlikely prospect of malignancy.

Following up on all of those was not an option at half past five in the afternoon, only 20 minutes were left before our group of eight medical students and a senior internist would share and discuss the day’s cases. So should I end the investigation once all reasonable causes had been exhausted, or embark on a blind journey, undefined in both direction and target?

I suddenly recalled a short story I once read. Tehila tells the story of a gentle Jerusalemite lady and was written by Shmuel Yosef Agnon, who was born in 1887. Tehila’s arranged marriage to Shraga, a devout orthodox boy, is cancelled when her father finds out that the groom and his father had visited the Rabbi of Hasidim, a Jewish mystic movement.

Tehila’s later life was shaped by terrible experiences until finally she understands her father’s serious misdemeanor and attempts to obtain Shraga’s forgiveness. Every one of her subsequent actions was inspired by the belief that a person has to accomplish an absolute number of words or concepts in their lifetime, and when this number is reached the time has come for their souls to depart from their bodies, ending all activity until the end of days resurrects all humans who were appropriately buried.

“The globe of the eye is limited” — Agnon evokes the invisibility of seemingly trivial life events and their unpredictable impact. Just as limited was my eye when I retrospectively scrutinised the diagnosis that I had missed: Coxiella burnetii was the infectious etiologic agent.

Being at an early stage in my medical career, I wonder whether with experience and knowledge I will grasp the amorphous line between pertinent clinical queries and far fetched but statistically possible ones.

Experienced professionals may know the answer to my question: if a personal interest in and interaction with patients is really the best way to tackle their suffering, how may that intricate balance be maintained in a way that would best serve both sides?

With Agnon’s words reverberating in my ears and the medical diagnostician’s hat momentarily adopted, should we restrict ourselves to an artificial word limit, sparing us bizarre, unrelated false positives, similar to Tehila’s word counting ritual?

Ohad Oren, fourth year medical student, Bruce Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel

Patient consent obtained.

  • Helen

    As a practitioner in the professions allied to medicine, I am often confronted with a similar challenge as described by Ohad Oren – often my intuition tells me that a diagnosis is not a complete fit to a patient, and my conventional management strategies are doing more harm than good..

    In the rushed world of medicine, much has been improved by clinical pathways, however the diagnoses which are statistically less likely are sometimes completely overlooked.

    I know my medical colleagues feel pressured and get anxious if their diagnosis is contradicted, but I have the privilege of more time and a more specialized focus.

    So please at least dignify my suggestions with a few minutes of your time, and I will do my best to present the evidence as a coherent whole.

    It is not my wish to embarrass you, it is my wish that we work in partnership to give the best care for these patients, the difficult “heart-sink” ones you often send me!

  • Dvoritte

    Very interesting point of view. I find that many long-experienced physicians, paradoxically though, tend to lose some of their awareness and curiosity, and are not as sensitive and attentive to seemingly-insignificant clinical clues as their patient would like them to be. What steps could be taken at medical schools to keep young medical graduates’ awareness and attentiveness to some of the bizarre triggers of modern diseases that very infrequently cause harm? Maybe create a journal section aimed at refreshing unusual clinical scenarios to prevent young physicians from being trapped in the ‘classical cases’ hazardous net?

  • Michal Oren

    Thank you for sharing with us your beautiful and illuminating thoughts about your medical experience. The question you pose is a one that I have long been contemplating. As I recall myself as a pre-clinical medical student, it always bothered me if someday, as a professional physician, I would be able to draw the imaginary notwithstanding very essential line between “pertinent clinical queries” and the “far fetched but statistically possible ones” that you relate to in your writing. As I see it now, from a much more clinical perspective taking into consideration all the limitations of the health care system (especially the one we have in Israel), no doubt medical staff cannot “afford” “wasting” its medical human resources when dealing, on the one hand, with straightforward diagnosis, while on the other hand more bizarre (and often lethal) diagnoses demand attention.