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    Weighing diagnosis with delivery

    Dermatology Times editorial

    Elaine Siegfried, M.D.Last summer I wrote a column about my passion for diagnostic medicine, a trait that prompted my brother, in a moment of irony, to diagnose me with ODD (obsessive diagnosing disorder).  I am stuck on the subject.

    READ: Clinical pearls in pediatric dermatology

    Physicians with ODD relish pathognomonic features and physician-educators love algorithms. Probability theory and information technology have enabled a more statistically analytic approach to the DDx that may one day replace the ODD physician. But the skill required to nail some diagnoses is so high-level that I doubt a computer will be able to replace a pediatric dermatologist in my lifetime.

    Considering an expanded DDx is time-consuming. Physicians with ODD are very thorough, but tend to run behind in clinic because we place a higher value on precision than punctuality. There have been many occasions when I have walked into a room, anticipating only the simple problem posted as the patient’s chief complaint or presented by the resident. But within minutes, I became aware of worrisome signs that prompted the need for a more detailed history and exam, turning what could have been a 5-minute visit into a 30-minute evaluation and counselling for a previously unrecognized syndrome.

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    The impact of a missed diagnosis can extend beyond the risks of the disease itself. In some cases, it triggers anxiety and mistrust of care provided for loved ones. On more than one occasion, I have been one of many physicians asked to evaluate the normal, healthy child of a parent who had been the victim of a missed critical diagnosis. A 10-year-old girl I saw last week for the third time in 6 months had been seen in the prior week by her pediatrician, by her allergist, and in the emergency room. The girl had received a thorough negative evaluation for an extensive DDx. So, my third evaluation focused on her mother’s concerns. Mom had suffered from a constellation of vague symptoms including hyperhidrosis, fatigue and headaches before acromegaly was suggested by a sorority sister-pediatrician who saw her at a 10 year reunion. That experience completely destroyed this mother’s faith in the medical system to guard her child’s health. Her daughter’s skin findings were subtle and inconsequential, but Mom’s missed diagnosis was an essential feature of a possible “vulnerable child syndrome” diagnosis. 

    NEXT: The ability to communicate a serious medical concern

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    Elaine Siegfried, M.D.
    Elaine Siegfried, M.D., is professor of pediatrics and dermatology, Saint Louis University Health Sciences Center, St. Louis, Mo. She ...

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