Diagnosis in surgery

[IR_2016]

From my inexperienced MS3 understanding, once a surgeon receives a referral the diagnosis has already been made and the next step for the surgeon is to analyze that individual patient's specific disease to develop a strategy to best treat that patient. Is the pattern more often than not that the Internist, PCP or Radiologist makes a diagnosis, and refers to the surgeon who fixes the problem? How much of a surgeon's time is spent diagnosing the diseases the treat?

To those of you who enjoyed the problem-solving and diagnostic aspects of your MS3 core IM clerkship, but who are now surgical residents/fellows/attendings, do you ever miss the mystery of trying to identify an elusive disease process? Or would you say in your practice you still get enough of that and, if so, how?

Thanks!

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[DoctwoB]

It's a mix. Some diagnosis are handed to you, e.g. Kid with classic appendicitis story, US confirms appy, exam consistent and that's what they call you with. Of course sometimes the diagnosis they give you are wrong, so you still need to do your own evaluation. Sometimes you'll get a patient with belly pain and they're concerned for appy but findings are equivocal and its up to your assessment and judgement. Other times youll get referred a patient for a symptom or radio graphic finding e.g belly pain or in my case, hydronephrosis and the work up and dx is on you.

 

[Winged Scapula]

Like noted above, it's a mix. Sometimes patients come to me already biopsied or with classic Imaging, and other times I'm the one doing the Imaging and biopsy, calling the patient with the results. It really depends on the referral patterns in your community.


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[surgonc2017]

As the others above said - it's a mix. There are plenty of times where the patient comes into clinic, diagnosis is secured - classic story, confirm they have the appropriate workup and the proceed to surgery. In this case surgery often has "problem-solving" that is similar to that of IM in surgical planning. How are you going to manage comorbities, what operative approach are you going to use, what are the unique obstacles to this patient, etc. This can even be an element in an ED call. Ruptured AAA, are you going to take the time to go to the scanner - try to put together something endovascular, go straight to the OR for an open procedure? etc.

There's a weird category of patients which present with a diagnosis already assigned to them, but really an inappropriate workup or story for that diagnosis. These are some of the most and least satisfying patients for me. Finding the right diagnosis and getting them to an appropriate specialist is often rewarding, but running down extra labs to confirm what you already thought in order to schedule surgery later - less so.

Often I'll get called by the emergency department with more or less a chief complaint and haphazard workup that hasn't shown much. "Abdominal pain with negative CT scan" - in this case you're pretty much it for working up the patient or explaining to the ED physician why this isn't your problem. There's also the unique element of surgery that is trauma. The patients show up injured and even though you know it's an motor vehicle crash, gunshot wound, electrocution etc. etc. you have to figure out how the patient is injured and develop a treatment plan rapidly in real time.

There's also post-operative patients. Even though you may have treated their initial problem with a surgery, patients develop additional post-op findings frequently. These may be simple like electrolyte deficiencies, or may be a complex cardiac arrhythmia, an anastomotic leak. These require some level of differential diagnosis and the ability to manage critical illness.

In conclusion, the main challenge of surgery isn't usually "diagnosis" per se, but complex problem-solving and priority assignment are still HUGE aspects of surgery that manifest in different ways than internal medicine. Also, you get to operate - and that's pretty awesome.

 

[caffeinemia]

And sometimes, the diagnosis isn't made until after the surgery. It's called an exlap for a reason; but maybe that's a thing of the past now with super high res ct scanners and mris and such.

But hell, you never know what you'll biopsy or what benign lump turns out to be a nasty malignant tumor.

 

[ACSurgeon]

In addition to te above- making a diagnosis isn't just when you get a history and physical and try to define the problem and make a plan. You have to pay attention to subtle clues to diagnose perioperative issues before they hurt your patient. That's a much harder type of diagnosis to make then seeing a patient in clinic or the ER and ordering a bunch of tests.

Also, it's not uncommon for us to be called about a "diagnosis", only to find out it is wrong.

 

[dpmd]

I have plenty of opportunity for diagnosing stuff,but I do sort of enjoy when the diagnosis is made and actually correct.

 

[caffeinemia]

Imho I've said this before but fascination with the novelty of diagnosis is largely a med-student and pre-med thing.

After several years of residency even, the things that seem novel to students are mundane to us.

Just imagine after ten or twenty years in practice. It's pretty rare that you're stumped or impressed by something when you've seen it and evaluated it hundreds of times.

If i get "consulted" for another "is this an iv infiltration?" in peds hospital again this year, I'm gonna start doing some bedside amps at the wrist level.

That said, one of the reasons I like PRS is that at the higher level, the diagnosis is more.... how can this be repaired or made better, versus what is this disease entity? So when I look at a fugly nose or something, I'm not thinking about the cause of it, but moreso what is not aesthetically unpleasing about it... which can be nuanced.

 

[caffeinemia]

Yeah but that's less "diagnosis" than it is operative planning. Same way I like looking at CTs of giant cancers and trying to think about how to safely remove them and where the blood supply is going.

On a related note, I remember as a junior going to plastics/aesthetics clinic and listening to the plastics chief describe someone's facial features to the attending and what surgery they could offer. I was fascinated and half wanted/dreaded to ask them what they thought was wrong with my face!

Haha. That's what I mean by diagnosis though... accurately pinpointing what the heck is going on when say a pt complains -- I don't like my nose.

That said, I turn off the facial analysis when I'm with friends, colleagues, etc. People aren't patients unless they want to be, and even then, only if they payyyyy meh

 

[Psai]

Yeah but that's less "diagnosis" than it is operative planning. Same way I like looking at CTs of giant cancers and trying to think about how to safely remove them and where the blood supply is going.

On a related note, I remember as a junior going to plastics/aesthetics clinic and listening to the plastics chief describe someone's facial features to the attending and what surgery they could offer. I was fascinated and half wanted/dreaded to ask them what they thought was wrong with my face!

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[dienekes88]

Imho I've said this before but fascination with the novelty of diagnosis is largely a med-student and pre-med thing.

After several years of residency even, the things that seem novel to students are mundane to us.

Just imagine after ten or twenty years in practice. It's pretty rare that you're stumped or impressed by something when you've seen it and evaluated it hundreds of times.

Yes and no. I think that we as surgeons have a certain set of diagnoses that we deal with, and the pre-test probability of the diagnosis is quite high by the time we are called. On the other hand, the completely undifferentiated patient in the community presenting to the ED or the primary care physician... the diagnoses we see frequently are suddenly not so frequent. Most of the time it's pretty run of the mill stuff for these guys on the front lines, but a few rare cases of unusual things can get folks pretty excited. You mention cancer whacks... It's not too common that a patient with jaundice and a little weight loss gets no work up and shows up in the surgical oncologist's office. The months I spent in clinic, they always had a variety of CT scans, maybe an endoscopic ultrasound, a biopsy or two, etc.

Surgical specialties with a complementary diagnostic/internal medicine specialty seem to have less diagnosis involved: cardiology and cardiac surgery, neurology and neurosurgery... maybe even gastroenterology and colorectal surgery (?). Surgical specialties without a complementary medicine specialty field seem to require a little more diagnostic focus: ENT, urology, and ophthalmology.

Yeah but that's less "diagnosis" than it is operative planning. Same way I like looking at CTs of giant cancers and trying to think about how to safely remove them and where the blood supply is going.

On a related note, I remember as a junior going to plastics/aesthetics clinic and listening to the plastics chief describe someone's facial features to the attending and what surgery they could offer. I was fascinated and half wanted/dreaded to ask them what they thought was wrong with my face!

Haha. I think it's both operative planning and diagnosis, though half the diagnosis comes from the patient.

 

[vhawk]

Yeah but that's less "diagnosis" than it is operative planning. Same way I like looking at CTs of giant cancers and trying to think about how to safely remove them and where the blood supply is going.

On a related note, I remember as a junior going to plastics/aesthetics clinic and listening to the plastics chief describe someone's facial features to the attending and what surgery they could offer. I was fascinated and half wanted/dreaded to ask them what they thought was wrong with my face!

Yeah agree with this. Its still the same thrill, that of cleverly solving a problem, its just that as you gain experience you realize that the things you thought were so clever as a midlevel resident become more routine and you have to find harder and harder problems to solve. Its a little like heroin addiction that way. By the time you become a gray hair the "interesting" problems become solving insoluble social situations and finding ways to mobilize hospital resources efficiently.