In the resident room at our hospital, we have a dry-erase board that plays an important role in resident education. On one side of the board, residents write the emergency department's (ED's) diagnoses of patients admitted to the medicine service. On the other side of the board, they write the actual diagnosis of each patient. Although some of the words in the below image of the board might be a little fuzzy, I promise you, many of them are hilarious:
I'm not gonna lie: most of the words on this board positively drip disdain. Fairly or not--and certainly, as is common in many institutions--our ED is viewed as a place where actual medicine is practiced only about 50% of the time, on a good day. Although I believe this is largely due to the crummy systems in our ED, the "ED personality" plays a significant role in it, as well. Emergency doctors are under incredible pressure to move people through the system. Plus, they've all watched a lot of "ER." Hastiness and machismo are bad on their own, and terrible in combination.
I'm not sure the board exists entirely for the purpose of poking fun, however. There's a message here: inpatient medicine can be very non-linear. We often think we know it all after a first impression, but we're often wrong. Internal medicine residents could just as easily create this kind of a board with our own admitting and discharge diagnoses of patients, even though we have a lot more time, nursing, and resources than the ED does. It's not because we're stupid; it's because the process of diagnosis is incredibly complex.
Still, a teaching point for the learners out there: "lack of normal physiology" is not an admitting diagnosis.
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Thanks, Signout, thanks for that. I just spit coffee everywhere.
I gotta say, having worked in the ED at your institution, is that there is not a lot of machismo there. And as much as I think that the ED at your institution is one of the worst EDs in the history of God's green earth, I think you're selling them and maybe EM as a whole a bit short. Watching ER does not a philandering cowboy of an emergency physician make...as much as watching House does not a drug-addicted asshole of an internal medicine doctor make. Still I'd like to see most medicine residents tackle an ED thoracotomy. Sometimes the cowboy mentality is needed to actually treat and save the patients in a timely manor...without rounding on them.
I think it would be pretty interesting if on the IM side of the board, you put the time it took you guys to come to the actual diagnosis. Diagnoses can take a while to declare themselves...time you have while you're rounding for 16 hours on patients that sit on the wards for 10 days. While moving the room is an offensive entity, it's sadly the only way to get a ridiculous amount of patients through the ED with the ED overcrowding catastrophe facing the US. And while stretching the truth on an admitting diagnosis is offensive as well, it's sadly necessary at times to get obviously "sick" patients out of the ED and into the wards where there is time to monitor them and come to the actual diagnosis in a not so hasty manor...particularly at a place where IM can deny admissions.
Commenting on the board specifically, hypertensive emergency (IM diagnosis on the board) is, if not all the way out, becoming an unrecognized entity in medicine and should really never be an official diagnosis. If I had scabies, I'm pretty sure I'd have mental status changes...shit I'm having thoughts of formication just writing about scabies. I'll bet the person with compartment syndrome was actually anemic as well...and I have trouble believing it wasn't the probable surgical consult that caught the compartment syndrome...or the necrotizing fasciitis.
There's this animosity between internal medicine and emergency medicine which is sad and totally hinders good patient care. As much as I got pissed off about having to admit another relatively healthy patient with a shit ass ED diagnosis who got discharged at 8AM the next morning last year as a IM intern, I also got pissed off when the MICU balked at admitting a pt who had received chemo 10 days ago for CLL and was coming in with borderline hypotension, a clinical and radiographic pneumonia, and a fever of 102.4 for sepsis secondary to probable neutropenia because the wbc count hadn't surfaced yet...which turned out to be 0.9. Internal medicine complains about admissions and tries to block them. It's what they do. It's what I did last year. It's about as good for the patients as moving the room.
All that being said, "lack of normal physiology" should never ever be an admitting diagnosisever.
Maybe not in your hospital, but probably in another one, is a white-board in a window-less basement, where the pathology department is writing down what the patient really had, and deploring what the staff upstairs thought it was.
I think people differ greatly on this issue. For example, if it were completely unidentifiable as my own, I would have no problem with a picture of my naked ass being posted on the Internet. Others would be absolutely horrified by the prospect.
Signout reader named Benjamin Langer, who himself has a very nice critical piece on intelligent design in the current edition of SCQ.