Thread by @medicalaxioms

About half the greatest cases you might see in the hospital are hiding behind wrong diagnoses made by lesser minds than yours like:
- drug seeker
- malingerer
- liar
- cheat
- faker

“I checked for the usual 3 things” will rarely find you a rare diagnosis.

Trying to save money by not searching our less common diagnoses wastes money. And time. Precious time for the sick person.

If you think nobody has rare things, it’s because you have missed the last 10. Ten interesting shapes you have hammered into the same square hole.

I rarely see cheaters and drug seekers. Instead, I try to figure out what they are sick with. Most people turn out to be sick with something. Even if it’s addiction and withdrawal.

I’ve noticed that doctors who frequently see liars and cheats seldom can generate even a second item on the differential diagnosis for these patients.
This does not impress me.

Patients will see a number of these doctors before some sharp mind considers the second possibility. “Maybe you are sick with something.”

I saw a 30 ish man with Marfan Syndrome as an intern. He spent half a day in the ER with tearing abdominal pain. I told my resident everyone thought he was faking. He said, “He’s getting a CT, now.”

He had an aortic dissection of course. He survived surgery but developed spinal cord ischemia and never walked again.

I told my resident, “a bunch of doctors saw him before me and thought he was faking.”
“A bunch of doctors were wrong,” he answered. “Your job is to be right when nobody else is.”

Looking back this was the most drop kick one foot putt over the plate home run case in the world. The doctors (including me) had to forcibly force the obvious 2nd year med student test answer in this case.

I think people tripped over the simple fact that the guy looked like a young, very tall and skinny bearded Jesus. Complete with sandals. He was “not the kind of guy to have a real illness.”

From that day to this, I have stopped making flash judgments about degree of illness based on socioeconomic/personal style factors.

I have met a man addicted to heroin who ran a successful clothing business. I have met homeless people who haven’t had a sip of alcohol since before you were born.

Take the story at face value. Investigate the possible diseases that may manifest with these signs and symptoms. Leave the judgment of the person to their own personal god(s).