7 Jan, 15 | by Toby Hillman
Clinical curiosity is a key trait amongst learners, and in clinical practice, curiosity is necessary to reach a diagnosis of even the most simple nature, but particularly so to diagnose cases that do not readily fit the heuristics that one brings to bear in everyday clinical work.
However, clinical curiosity can be supressed by the requirements to learn a huge volume of ‘facts’, the time pressures of work, a culture where certainty is admired and rewarded, and uncertainty often frowned upon. Indeed, being able to see a case from many different perspectives, rather than picking a line and sticking to it can be very inefficient, but curiosity is vital to ensure that the first diagnosis for any given presentation isn’t adhered to just because it was the first one made, but is constantly re-evaluated, and tested against new information as it is acquired.
These ruminations on the subject of curiosity were prompted by a chat with a colleague about her often random questions to me about a diverse range of medical subjects. Her contention to a colleague was that curiosity should be the driving force in clinical medicine, to avoid clinicians becoming protocol-driven drones.
A recent paper in the PMJ also got me wondering a little bit about curiosity, and wondering if in fact we have lost a bit of this wonderful character trait in medicine, and left ourselves satisfied all to easily by diagnoses and treatments that seem right, but don’t quite cut the mustard?
The paper reports a retrospective observational study across three Trusts in London, examining the investigation and management of hyponatraemia in all patients in whom the condition was identified. Laboratory data were monitoried to identify cases, and once 100 cases were identified, the study stopped. The seriousness of the condition of hyponatraemia was highlighted with an inpatient mortality rate of 16% ( I hasten to point our that there is no claim of causation) and 9% of the patients required ITU admission.
However, what was the response of medical teams at the three centres? Well, it could be described as a little disappointing – with a diagnosis recorded in the notes of only 42% of patients. And these weren’t just low sodiums one might explain away; to be included in the study, the serum sodium had to be ≤128 mmol/L.
What was actually done for the patients? To fully evaluate a patient with hyponatraemia and reach a rational diagnosis, and hence management plan, the authors considered that a full set of: volume status, paired serum and urine osmolalities, urinary sodium, thyroid function tests, and cortisol. A complete work-up was performed in just 18% of patients across the three centres,
And the management – even if a diagnosis wasn’t achieved, what was acutally done?
37% of patients did not have any specific therapy at all, and predominantly patients received isotonic saline. Cessation of potentially causative drugs was next most utilised therapy, and this was followed by fluid restrictions to various degress,
Treatment failure was recorded in 15% of those treated with isotonic saline, and 80% of patients undergoing fluid restriction, and 63% of patients were discharged with persisting hyponatraemia – and as the authors indicate, this is perhaps not surprising given the lack of diagnosis, and treatment in many cases.
So what is going on? The most common electrolyte disturbance seen in hospitalised patients is easily diagnosed (try being admitted to hospital without having a U&E sent…) and yet is poorly investigated, diagnosed, and treated. Is this a reflection of a lack of guidelines, education and therapeutic options as the authors suggest?
I would point out that a simple internet search on any smartphone or computer for ‘hyponatraemia algorithm’ will generate a few options of how to assess and manage patients with hyponatraemia – so availability of guidance wouldn’t necessarily be a major barrier. However, I agree that there is perhaps not quite enough education on clinical chemistry in the medical curriculum.
But perhaps it is due to a diminution of the curiosity of clinicians – be that a result of the way we educate, train, or the efficiency we expect of our doctors that curbs the desire to seek the truth in complex cases, and leads to a satisfaction with first pass diagnoses rather than cradling diagnostic uncertainty, and going through the full work up that our patients need to manage their conditions.