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Medical Education and the 'Atypical' Presentation

One and a half years of medical school has at least taught me one thing: medicine is all about getting the right diagnosis.  Sure, there are important things like treatment, but honestly, evidence based treatment guidelines and experiential wisdom can all be looked up.  And as people realize that the way we teach is just as important as what we teach, most clinically savvy professors have done away with the old-school method of disease definitions.  These days they give us the symptoms, we generate a differential diagnosis (the list of likely issues based on the case history), and then we learn the diseases.

And so basically, as medical students we're taught pattern recognition and probabilities.  Have a person in the hospital that has sudden kidney failure a few days after an aggressive bacterial infection?  That's the classic pattern for aminoglycoside toxicity.

Or maybe you're told your patient who has a terrible cough that won't go away.  She's worried because she watched a movie with someone who had lung cancer that coughed in similar way.  Without any other information, sure, some sort of lung or throat cancer is on your differential.  Find out she's never smoked and hasn't had unexplained weight loss? Suddenly the chances of her having cancer are much lower.  And then it turns out she has high blood pressure and is on an ACE Inhibitor.  The odds are completely different now.  Cancer is way down and side effect of her medication is really high on the list.

But these are all likelihoods.  It's not impossible that our hospital patient wasn't given an aminoglycoside and has kidney disease independent of his/her previous infection.  Furthermore, no doctor would ever tell you that there's no chance that the cough is cancer.  40 year-olds who have never smoked sometimes get cancer and not all people on ACE Inhibitors cough.  We start with the most likely and move our way down.

My point is that in order for a diagnosis to be made, it has to make it onto the differential in the first place.  Furthermore, in order for a diagnosis to be made promptly, the physician has to have an accurate understanding of probabilities.

So what happens when those very probabilities are generated by historically white, male populations and they're taught as though they apply to everyone?  Diagnoses get missed and care suffers.  Certainly, medical institutions are starting to recognize this.  We're routinely told to scrutinize treatment studies that only study Caucasian males because unless your patient is a white guy, the study might not actually apply.  And just this week, during our dermatology sequence we were given a lecture entitled, “Dermatology of Pigmented Skin.”  In our cardiovascular sequence we were given a lecture entitled, “Cardiovascular Disease in Women.”

I have no doubt that this is a vast improvement from medical curricula in the past.  However, we can do better.

The lecture objectives from the dermatology talk:
-Define skin type designations
-Understand the biologic differences in darker skin types
-Discuss common conditions in skin of color
-Illustrate different presentations of diseases in various skin types



story | by Dr. Radut