Don't get complacent
As I'm in fellowship training, I often introduce myself as a fellow, but I find many patients don't have a clue what that means. Many know what a resident is (or at least they think they do) but have never heard of fellows.
Having to frequently explain where I am in my training gets me thinking again about what exactly my experience is.
I'm board-eligible in Orthopedic Surgery. I've been clinically learning and practicing it for over 5 years now (depending upon exactly how you define those terms).
Most patients who come into the office these days don't present the diagnostic challenge they once might have. I even readily identify "sub-clinical entities" (medical jargon for other, incidental, non-related problems that were sort of bothering the patient but not really to the level that they'd complain about it, and are not why they came to the office). While that makes me feel good about myself, it does have a tendency to keep me in the room for longer, explaining why a patient with very mild early carpal or cubital tunnel syndrome should wear splints to prevent it from worsening, when they just thought they were coming in for a trigger finger. (Don't let anybody tell you there is no preventive medicine in orthopedics)
It makes me feel a bit like Sherlock Holmes when I can amaze someone by deducing their sleeping habits, or how they hold a phone, or whether they just recently had a child, based only on examining their hands. I used to read Conan Doyle and think, "Nobody could ever do this today... look at someone's hands, see the ink stains, and deduce they were a printer. Or see some little callus and recognize a cobbler. Most modern jobs are fairly clean. And the ones that aren't are just obvious. Everybody knows what a mechanic's hands look like..."
But not so. The more patients I see, the more I realize there still are tiny, subtle exam clues that can allow powerful deductive reasoning.
But I was lucky enough today to have a (safe) humbling experience that reminded me that I don't know everything. A patient came in, two weeks after a fall, with radial sided wrist pain. X-rays were done on the day of injury and were read as negative. His specific complaints sounded pretty classic for DeQuervain's tenosynovitis (DQV), though in my mind something was saying, "this is weird, DQV doesn't usually present like this." So I examined him again, and found he was tender a bit more broadly than a typical DQV patient would be. Swollen too. And his grip strength, while still decent, was much lower than I had expected it to be ("well it hurts!" he said in his own defense).
He had some tenderness in the anatomical snuffbox, which in this patient's son or grandson would've been concerning for a scaphoid injury but much less so in his age group. It is conceivable the first x-rays would have missed a scaphoid fracture, that's actually pretty common, and it can have devastating consequences. I didn't really suspect he had a scaphoid fracture, it seemed very unlikely. But, just to be safe, I figured it would be reasonable to get X-rays in the office just to be sure he hadn't broken his scaphoid and it was just tendinitis. So, the x-rays were done, and the scaphoid looked fine. We went on assuming this was just a bad post-traumatic case of DQV and gave the man a steroid injection, planning for him to come back in a few months if it wasn't better, and to wear a splint some of the time to help with the swelling.
Literally on my way out the door, I turned and glanced at the x-ray one more time. Something wasn't right. There was a faint, longitudinal line in the radius (the larger of the two forearm bones, which is also partially shown on the wrist x-ray). "Huh," I remarked out loud to nobody in particular, "that's a funny looking nutrient artery. It's really long. In fact, it's the longest one I have ever seen. And it's very sharp. And it... enters the joint...?" Yeah. It was a fracture line. A non-displaced, incredibly subtle fracture that I was VERY lucky to notice because I happened to glance at the x-rays one final time for seemingly no reason at all.
Now, it was already two weeks old and hadn't displaced at all despite the patient not even knowing he had it (so not immobilizing it) - so it's safe to say it was a stable fracture. But there it was. I couldn't un-see it now. We changed course and told the patient to wear the splint round the clock. He was grateful we found it and seemed very understanding regarding the fact that we nearly entirely missed it. He was looking at the xray also, and remarked that he was amazed at how subtle it is.
I consider this a miss. Thankfully it was a safe miss, and by a freakish bit of luck I caught it before it was too late, but I whiffed on that one. If given the same encounter 10 more times on a different day (especially if I was in more of a rush than I was today) I doubt I'd have even ordered the x-ray all 10 times. And I'm sure that I'd completely miss the fracture some of those times even if I did order the x-ray.
But I know that had I done a better exam, and scrutinized the x-ray more thoroughly at the outset, we would've been able to diagnose it correctly from the start. Lesson learned... don't be too quick to whittle away the remainder of your differential diagnosis. It could always be something else. Make sure. Keep pushing yourself to be better. Notice the small stuff. Examine everything yourself. All the things we're trained to do, but (because we're human) don't do perfectly well 100% of the time.
I'm glad to have learned this lesson in a case where it was not that critical, and the outcome is unchanged. No harm at all, and probably wouldn't have even been at risk for very much harm even if it was missed entirely... it's likely he'd have healed completely by the time we saw him back (if he even kept the appointment), and we would've just chalked it up to an intense bout of tendinitis. This was the easy way to learn the lesson... I'm just glad it got recognized and I could learn from it, because the next one might not be as benign of a case.
Having to frequently explain where I am in my training gets me thinking again about what exactly my experience is.
I'm board-eligible in Orthopedic Surgery. I've been clinically learning and practicing it for over 5 years now (depending upon exactly how you define those terms).
Most patients who come into the office these days don't present the diagnostic challenge they once might have. I even readily identify "sub-clinical entities" (medical jargon for other, incidental, non-related problems that were sort of bothering the patient but not really to the level that they'd complain about it, and are not why they came to the office). While that makes me feel good about myself, it does have a tendency to keep me in the room for longer, explaining why a patient with very mild early carpal or cubital tunnel syndrome should wear splints to prevent it from worsening, when they just thought they were coming in for a trigger finger. (Don't let anybody tell you there is no preventive medicine in orthopedics)
It makes me feel a bit like Sherlock Holmes when I can amaze someone by deducing their sleeping habits, or how they hold a phone, or whether they just recently had a child, based only on examining their hands. I used to read Conan Doyle and think, "Nobody could ever do this today... look at someone's hands, see the ink stains, and deduce they were a printer. Or see some little callus and recognize a cobbler. Most modern jobs are fairly clean. And the ones that aren't are just obvious. Everybody knows what a mechanic's hands look like..."
But not so. The more patients I see, the more I realize there still are tiny, subtle exam clues that can allow powerful deductive reasoning.
But I was lucky enough today to have a (safe) humbling experience that reminded me that I don't know everything. A patient came in, two weeks after a fall, with radial sided wrist pain. X-rays were done on the day of injury and were read as negative. His specific complaints sounded pretty classic for DeQuervain's tenosynovitis (DQV), though in my mind something was saying, "this is weird, DQV doesn't usually present like this." So I examined him again, and found he was tender a bit more broadly than a typical DQV patient would be. Swollen too. And his grip strength, while still decent, was much lower than I had expected it to be ("well it hurts!" he said in his own defense).
He had some tenderness in the anatomical snuffbox, which in this patient's son or grandson would've been concerning for a scaphoid injury but much less so in his age group. It is conceivable the first x-rays would have missed a scaphoid fracture, that's actually pretty common, and it can have devastating consequences. I didn't really suspect he had a scaphoid fracture, it seemed very unlikely. But, just to be safe, I figured it would be reasonable to get X-rays in the office just to be sure he hadn't broken his scaphoid and it was just tendinitis. So, the x-rays were done, and the scaphoid looked fine. We went on assuming this was just a bad post-traumatic case of DQV and gave the man a steroid injection, planning for him to come back in a few months if it wasn't better, and to wear a splint some of the time to help with the swelling.
Literally on my way out the door, I turned and glanced at the x-ray one more time. Something wasn't right. There was a faint, longitudinal line in the radius (the larger of the two forearm bones, which is also partially shown on the wrist x-ray). "Huh," I remarked out loud to nobody in particular, "that's a funny looking nutrient artery. It's really long. In fact, it's the longest one I have ever seen. And it's very sharp. And it... enters the joint...?" Yeah. It was a fracture line. A non-displaced, incredibly subtle fracture that I was VERY lucky to notice because I happened to glance at the x-rays one final time for seemingly no reason at all.
Now, it was already two weeks old and hadn't displaced at all despite the patient not even knowing he had it (so not immobilizing it) - so it's safe to say it was a stable fracture. But there it was. I couldn't un-see it now. We changed course and told the patient to wear the splint round the clock. He was grateful we found it and seemed very understanding regarding the fact that we nearly entirely missed it. He was looking at the xray also, and remarked that he was amazed at how subtle it is.
I consider this a miss. Thankfully it was a safe miss, and by a freakish bit of luck I caught it before it was too late, but I whiffed on that one. If given the same encounter 10 more times on a different day (especially if I was in more of a rush than I was today) I doubt I'd have even ordered the x-ray all 10 times. And I'm sure that I'd completely miss the fracture some of those times even if I did order the x-ray.
But I know that had I done a better exam, and scrutinized the x-ray more thoroughly at the outset, we would've been able to diagnose it correctly from the start. Lesson learned... don't be too quick to whittle away the remainder of your differential diagnosis. It could always be something else. Make sure. Keep pushing yourself to be better. Notice the small stuff. Examine everything yourself. All the things we're trained to do, but (because we're human) don't do perfectly well 100% of the time.
I'm glad to have learned this lesson in a case where it was not that critical, and the outcome is unchanged. No harm at all, and probably wouldn't have even been at risk for very much harm even if it was missed entirely... it's likely he'd have healed completely by the time we saw him back (if he even kept the appointment), and we would've just chalked it up to an intense bout of tendinitis. This was the easy way to learn the lesson... I'm just glad it got recognized and I could learn from it, because the next one might not be as benign of a case.
No one cares how much you know, until they know how much you care. Experience is a great equalizer, young grasshopper. Pt is lucky to have you on their team
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