Correspondence

Clinical Problem-Solving: Things Are Seldom What They Seem

N Engl J Med 1993; 328:1200April 22, 1993

Article

To the Editor:

In a recent piece in the Journal's Clinical Problem-Solving series (Dec. 3 issue),1 a patient is presented who initially appears to have alcoholic hepatitis, but is ultimately given a diagnosis of hepatoma. Although the discussion is excellent, the title and the final line of the essay -- “In clinical medicine . . . `Things are seldom what they seem”' -- generalize inappropriately from the case report.

Unlike the situation in this particular case, in clinical medicine things are usually just what they seem. Nevertheless, even when cases are quite straightforward, the trend in contemporary medicine is to pursue every last bit of uncertainty, even when that pursuit is unlikely to influence the clinical outcome. Kassirer has criticized this phenomenon as “our stubborn quest for diagnostic certainty”2. In fact, the very first article in the Clinical Problem-Solving series illustrated the pitfalls of pursuing incidental findings without regard for the larger clinical context3.

It would be unfortunate to send a message to students and trainees that things are seldom what they seem. A more appropriate message might be the following: “In clinical medicine things are frequently what they seem, but one must remain alert for exceptions to this general rule.”

Allan S. Brett, M.D.
Richard Parker, M.D.
Deaconess Hospital, Boston, MA 02215

3 References

1. 1

   Thibault GE. Things are seldom what they seem. N Engl J Med 1992;327:1663-1666
   Full Text | Web of Science | Medline

2. 2

   Kassirer JP. Our stubborn quest for diagnostic certainty: a cause of excessive testing. N Engl J Med 1989;320:1489-1491
   Full Text | Web of Science | Medline

3. 3

   Pauker SG, Kopelman RI. Trapped by an incidental finding. N Engl J Med 1992;326:40-43
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Thibault replies:

To the Editor: I agree heartily that we should discourage the quest for certainty when further testing is unlikely to influence the clinical outcome. In the Clinical Problem-Solving series we try to stress the use of clinical reasoning and probabilistic thinking to guide diagnostic and therapeutic decisions. We also try to capture some of the excitement of clinical medicine by using real case reports and problems, thus including the mistakes and surprises that keep us stimulated and ever vigilant. It was that sense of surprise and excitement that I was trying to capture by using as a title the line from the clever dialogue between Buttercup and Captain in H.M.S. Pinafore.

George E. Thibault, M.D.
Veterans Affairs Medical Center, West Roxbury, MA 02132

Citing Articles (1)

Citing Articles

1. 1

   Marshall B. Kapp. (1999) Commentary: Anxieties as a Legal Impediment to the Doctor-Proxy Relationship. The Journal of Law, Medicine & Ethics 27:1, 69-73
   CrossRef