Correspondence

Clinical Problem-Solving: Treating before Knowing

N Engl J Med 1993; 328:582-583February 25, 1993

Article

To the Editor:

I very much enjoyed reading the Clinical Problem-Solving article “Treating before Knowing” (Nov. 5 issue).1 Perhaps it was the discussant's training as a nephrologist that caused him to zero in on the glomerulonephritis. It was also probably my background as a pulmonologist that had me asking myself as I read, “But what about the green sputum?” Certainly Group A streptococcal community-acquired pneumonia is not a commonly recognized entity. What I find most interesting about the article is that the physicians caring for this patient were able to obtain the results of assays for antineutrophil cytoplasmic antibodies, antinuclear antibodies, complement levels, and anti-glomerular basement membrane antibodies, as well as a renal biopsy, before they were able to get the results of a sputum culture. The last paragraph laments that the positive sputum-culture results were not available in a timely fashion. The results were certainly available to someone.

The reasoning these physicians demonstrated in their diagnosis and therapy of the patient is certainly an example of medical excellence. Nevertheless, we should not forget the basics of the history taking and physical examination and the importance of compulsive attention to data gathering. Although being smart is always an asset, scut work can take us a long way.

Bennett E. Ojserkis, M.D.
Atlantic Shore Pulmonary Associates, P.A., Linwood, NJ 08221

1 References

1. 1

   Parker SG, Kopelman RI. Treating before knowing. N Engl J Med 1992;327:1366-1369
   Full Text | Web of Science | Medline

To the Editor:

In “Treating before Knowing,” Pauker and Kopelman presented the case of a 52-year-old man with progressive dyspnea, productive cough, and fever along with a chest film demonstrating bilateral infiltrates. The history as presented noted that there was no history of drug abuse and that the patient was not gay. From this, the clinician concluded that there were no risk factors for human immunodeficiency virus (HIV) infection. I do not think that the history presented was sufficient to discount the possibility of HIV or of opportunistic infection.

When the acquired immunodeficiency syndrome was first described, it had the stigma of being a disease of homosexual men and drug abusers. Of course, most people now know that this is not the case -- HIV has no predetermined selection criteria. An adequate history should include a thorough sexual history, including information on single episodes of risky behavior, along with a history of injection-drug use and transfusions of blood products. Even though the patient is not homosexual, he may be bisexual, or he may have had promiscuous sexual encounters with either sex, and he would probably not have volunteered this information if asked only whether he was gay.

Interestingly, the patient presented in Case Record 44-1992, in the same issue of the Journal,1 a 60-year-old bisexual man who was HIV-positive, would have answered no if asked only whether he was gay. A comprehensive assessment of risk factors should be part of every medical history; these two cases illustrate the importance of this, especially in patients who are older than the typical HIV-positive patient.

Ronald L. Hirsch, M.D.
Key Medical Group, Ltd., Carpentersville, IL 60110

1 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 44-1992). N Engl J Med 1992;327:1370-1376
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: As Dr. Ojserkis suggests, the results of the sputum culture were probably available to someone in a timely fashion. Perhaps because the initial tests were performed in a local clinic, the clinicians treating the patient in the hospital did not have those data until the third day. Although this logistic problem should be easy to remedy, we believe that it reflects one of the major problems in many current, splintered systems of health care delivery. The flow of clinical data (and indeed of new medical knowledge) can swamp our ability to absorb and integrate, but outdated and inadequate modes of communication can delay or prevent our response to even straightforward data. The transmission of information from one institution to another (in this case from an outpatient clinic to an acute care hospital) is one of our weakest links. It usually depends on manual systems and, even then, often occurs at the moment the patient is transferred or referred. Here, a test result that was reported after the referral took place was probably communicated only when a health care provider in the clinic realized that it might be of interest. Such communication should be an automated part of an established system.

Dr. Hirsch is correct: HIV infection is surely not limited to intravenous drug abusers and gay men. We should focus our attention to risk on forms of behavior rather than groups of people. Our inclusion of the material as it appeared in the medical record was neither an endorsement of outmoded attitudes nor an exhaustive list of the kinds of behavior that place our patients at risk for HIV infection. As the pool of infected patients continues to swell and as long-term monogamous relationships become less prevalent, the group of people at risk for HIV infection will increasingly encompass virtually everyone who is sexually active.

Stephen G. Pauker, M.D.
Richard I. Kopelman, M.D.
Tufts University-New England Medical Center, Boston, MA 02111