Poll: Does your school give lectures on diagnosis?

[unsung]

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Alright guys, I want to know if your school actually gave lectures on the following:

-- pathophys of fevers & chills (i.e. what actually causes the basic sxs & signs of an infection)

-- "how to diagnose" (i.e. how to think about diagnosis in a systematic fashion)


I ask 'cuz my school obviously didn't. 😉

And it just occurred to me... if a patient asked me now to explain WHY her specific illness was causing her chills, I wouldn't even be able to explain it. You'd think (or at least, I did, prior to attending med school), that a doc would know the answer to basic Qs on pathophys, such as the above.

Or why does a fever result in thrombocytopenia? It's just WEIRD to me that our so-called "pathophys" lectures just spew out a bunch of genetic markers at us, and pretend it's pathophys, when it's not.

I would've liked to have learned WHY our body responds the way it does to general classes of illness. (We get a LITTLE bit-- such as why some trigger type 4 hypersensitivity (req Th cells), while others do not, etc...-- but definitely the focus isn't on this type of info.)

Anyway, to this day, I don't know why lymphocyte count is related to viral infections typically, whereas PMNs respond to bacteria. (Please feel free to enlighten me.)

On a slightly unrelated note, I'm also a little baffled why med school isn't structured to actually TEACH us on how to diagnose. Since that's the actual meat of the job. Instead, we're given info disease by disease, without focusing on how to distinguish one entity from another.

For ex: Vomiting. How do we decide whether that's a symptom of GI trouble or increased intracranial pressure, etc.

Sure, I ended figuring these things out for myself. (Look for associated sxs, basically.) Also learned "VINDICATE", and figured out which signs/sxs suggest one category of illness vs. another. (Which is not to say I understand the actual pathophys behind why the sign is suggestive of the category... ha.)

Or... maybe the real answer is that medical diagnosis actually isn't systematic, and is more of a guess & check procedure based on "what's common" (i.e. what's likely). ("Flu is common", match sxs of flu to sxs of patient --> cross-check patient's demographics, guess the patient most likely have the flu... send patient home, if things do not improve, re-assess diagnosis)

I really really like the idea of systematically ferreting out a diagnosis, however. 🙄

Am I the only one bugged by this? I think I'm in the minority, 'cuz most personality types "drawn" to medicine seem to have no problems memorizing a bunch of sxs/signs, and doing the guess & check thing. You don't need much of a "system" to dx sinusitis, right?

Whereas I'm always looking for like an "optimal" systematic way of figuring out a diagnosis... so it's really appealing when renal divides it up into pre-renal/renal/post-renal, or neuro talks about systematic way to "localize the lesion". It gives me PLEASURE to do this. haha

I'd like to be able to use "logic" to systematically problem-solve & figure out a diagnosis. But the more I'm exposed to medicine, the more I'm realizing much of it is simply pattern recognition. (And additional years of "experience" on the job is simply a way of refining & imprinting those patterns into our heads, until "diagnosis" becomes automatic.)

The thing is, this kind of pattern recognition may "impress" a layperson who has no idea how you figured something out from seemingly little info... but really there wasn't a lot of thinking involved. And even if a disease is rare, such as Wegener's, once you've encountered it ONCE, you'll be able to diagnose the next case with no problem. The densest physician is capable of doing this... and of course s/he will "sound smart" when making that diagnosis that 2nd go-around.

Am I the only one annoyed by this?

 

[achamess]

Ditto. I wish I could say that that occurs at my school, but I can't. It's a worthy goal. I think your best bet might just be seeking out your own answers. Go to big Robbins and other resources and see why certain symptoms occur with certain diseases rather than just random markers. It'd be great if someone guided us through that process, but that might be asking too much.

 

[drizzt3117]

I think the first pt is mostly immunology (pathophys of the acute phase) and I can't imagine most schools don't teach you how to create a differential dx...

 

[Gabby]

On a slightly unrelated note, I'm also a little baffled why med school isn't structured to actually TEACH us on how to diagnose. Since that's the actual meat of the job. Instead, we're given info disease by disease, without focusing on how to distinguish one entity from another.

For ex: Vomiting. How do we decide whether that's a symptom of GI trouble or increased intracranial pressure, etc.

I think I'm misunderstanding you. Are you saying that your school never taught you the ins and outs of vomiting -- viral gastritis versus food poisoning versus neuro problems versus cycling vomiting, etc, the symptoms, what differentiates them, what tests to order, etc. How is that possible?

Are you talking about the very basics of a fever (temp set-point regulated by the hypothalamus?) or more detailed pathophys?

 

[osumc2014]

see that is the thing,that physicians don't have to be geniuses like many med students are, the only reason many of us are very bright is because how competitive the schools are. Dx is pattern recog which takes practice, surgery is procedures that take much practice to perfect. There really isn't much abstract thinking I believe

 

[Gabby]

see that is the thing,that physicians don't have to be geniuses like many med students are, the only reason many of us are very bright is because how competitive the schools are. Dx is pattern recog which takes practice, surgery is procedures that take much practice to perfect. There really isn't much abstract thinking I believe

I disagree with this. Sure, you'll have your bread and butter cases, but in most specialties, I think you will need to rely on the abstract at least a few times during your career.

For me, I need to know the why before I can "memorize" anything. Thankfully, my school is very good at this. We're never given symptoms without the why. In fact, we're tested on the why. All our tests are clinical scenarios and rarely are they asking for just the diagnosis. Most of the time, they want the diagnosis and treatment or diagnosis and other symptoms or they want to know why a certain symptom presents like it does.

 

[Rollo]

If I'm not mistaken, you see PMNs with bacteria because Ig's respond and they activate the classical complement pathway and one of the products of this pathway is C5a which is chemotaxis for neutrophils. While you see lymphocytes with virals because of CD8 Th2 activation.

That's how I understand it to be, I could be very well way off my explanation.

Anyway, I think lot of these intricate details our profs want us to learn on our own because it would take too much time to explain these mechanisms. And med school faculty are SUPPOSED to be going over big picture things (they sometimes don't because they end up talking about genetic markers or their favorite vasculitis disorder).

There are a lot of proven/proposed mechanisms for signs and symptoms you see with classic bread-and-butter pathologies. Lot of these can be found in Robbins (but who has time to read that?) and sometimes they are explained in Harrisons (again, who has time to read this monster either?).

Now, having said all of that, do I think that medical schools need to take the time to explain these mechanisms? Absolutely! What I would love more than anything is to have weekly 1-2 hour sessions with an expert on these mechanisms who can sit down with a small group of people and go over these topics. Can you imagine how productive and useful these types of sessions would be?

 

[hrandani]

While we're at it, can anybody explain to me now pheochromocytoma and neuroblastoma are different? I've looked them both up in every resource I can find and haven't had much luck in really nailing down exactly why they aren't the same thing or at least related. I feel like I'm missing something.

If it's any consolation, unsung, my school takes great pride in their pathophys class and it was a hilariously awful waste of time. I learned more in an hour skimming a bootleg pdf of clinical pathophys made ridiculously simple.

 

[mdeast]

Are you talking about differential diagnosis? I don't understand how your school cannot teach that? That's basically an essential part of being a physician and doing well in your clerkship rotations. It's part of our first and second year curriculum once you hit the disease blocks. You spend once a week in small group going over a case study and learning how to eliminate possibilities based upon tests and symptoms. We have exams on this as well.

As for fever and chills.... Immune system signals to the hypothalamus to increase body temperature (PGE2 increase) when a heightened immune state is activated by a persistent infection. This fights any temperature sensitive pathogens, plus T cells and macrophages tend to work better at higher temperatures. I'm not sure of the pathiophysiology of how muscle chills happen...but it's actually an additional mechanism to provide more body heat by systematically contracting the muscles.

 

[Parietal Lobe]

As for fever and chills.... Immune system signals to the hypothalamus to increase body temperature (PGE2 increase) when a heightened immune state is activated by a persistent infection. This fights any temperature sensitive pathogens, plus T cells and macrophages tend to work better at higher temperatures. I'm not sure of the pathiophysiology of how muscle chills happen...but it's actually an additional mechanism to provide more body heat by systematically contracting the muscles.

Muscle chills happen by muscle contraction, the regular way. That's how I was taught anyway. The hypothalamus regulates your temperature set point, like Gabby said. When there's infection, it raises the set point to isolate the infection and allow the immune system time to work. The body realizes the set point has been raised and this leads to shivering to get you warm. Once you hit the set point, if you go over it or the infection is taken care of, you'll sweat to cool yourself off.

One difference between fever and hypo and hyperthermia is that the set point doesn't change in the latter. In fever, the set point is raised (chills). After, it's lowered (sweating). In hypo/hyperthermia, your body is going either above or below the hypothalamic set point due to environmental circumstances.

Like a few others, I don't understand why your school wouldn't teach you all this. We learned fever and chills and the pathophys behind it the first month of school.

I attend a DO school and we don't get a single lecture that doesn't include this stuff, plus a list of differentials and how they differ from the diagnosis. At the end of every lecture, we get a couple of patient cases where we work through the disease process we were just taught and learn to eliminate our differentials and why they're eliminated. But even our straight-up anatomy, biochem, micro, and immunology lectures had a ton of clinical coorelations and how they relate to what we were learning and why. I figured that's how it was at every med school.

 

[unsung]

Muscle chills happen by muscle contraction, the regular way. That's how I was taught anyway. The hypothalamus regulates your temperature set point, like Gabby said. When there's infection, it raises the set point to isolate the infection and allow the immune system time to work. The body realizes the set point has been raised and this leads to shivering to get you warm. Once you hit the set point, if you go over it or the infection is taken care of, you'll sweat to cool yourself off.

One difference between fever and hypo and hyperthermia is that the set point doesn't change in the latter. In fever, the set point is raised (chills). After, it's lowered (sweating). In hypo/hyperthermia, your body is going either above or below the hypothalamic set point due to environmental circumstances.

Like a few others, I don't understand why your school wouldn't teach you all this. We learned fever and chills and the pathophys behind it the first month of school.

I attend a DO school and we don't get a single lecture that doesn't include this stuff, plus a list of differentials and how they differ from the diagnosis. At the end of every lecture, we get a couple of patient cases where we work through the disease process we were just taught and learn to eliminate our differentials and why they're eliminated. But even our straight-up anatomy, biochem, micro, and immunology lectures had a ton of clinical coorelations and how they relate to what we were learning and why. I figured that's how it was at every med school.

Yeah, well thanks for the responses guys. I guess instead of complaining, I should get off my @#$ and just google some of this stuff.

So... I wouldn't say my school didn't teach me this stuff. It's just that the courses are so disorganized, it's almost like they're "hiding" the important info (important in the sense that they're things that I want to know). Things like "T cells & macrophages work better at higher temperatures"... or "complement activation is enhanced by acidic environment, such as respiratory acidosis which occurs at night".

Or... maybe I should just read Robbins or some other tome, and I wouldn't have these Qs/issues. 🙄 Oh well.

Also, I'm not saying my school didn't teach me at all how to make a DDx... lol. It's just that much of that type of "how-to" was done very informally, in the context of small groups, or with individual preceptors.

I "would've liked" to have received some of that instruction in more formal, didactic lectures. 'Cuz... I just like to have some kind of theoretical framework for how to approach diagnosis, rather than just piece it together by emulating idiosyncratic ways different clinicians like to do things. For example-- how to decide when a constellation of symptoms should be considered together as part of one illness? VS considered separately as simultaneously occurring, discrete disease processes?

This is just personal preference. I suspect other ppl in my same shoes might find the instruction perfectly adequate.

I did find this book, that talks about DDx by symptom, such as "dizziness", "abdominal pain", etc. Anyone read/use this book?

http://www.amazon.com/CURRENT-Medic...LANGE/dp/0071700552/ref=reg_hu-rd_add_1_dp_T2

I wonder if it's worth buying.

 

[MDpride]

Yeah, well thanks for the responses guys. I guess instead of complaining, I should get off my @#$ and just google some of this stuff.

So... I wouldn't say my school didn't teach me this stuff. It's just that the courses are so disorganized, it's almost like they're "hiding" the important info (important in the sense that they're things that I want to know). Things like "T cells & macrophages work better at higher temperatures"... or "complement activation is enhanced by acidic environment, such as respiratory acidosis which occurs at night".

Or... maybe I should just read Robbins or some other tome, and I wouldn't have these Qs/issues. 🙄 Oh well.

Also, I'm not saying my school didn't teach me at all how to make a DDx... lol. It's just that much of that type of "how-to" was done very informally, in the context of small groups, or with individual preceptors.

I "would've liked" to have received some of that instruction in more formal, didactic lectures. 'Cuz... I just like to have some kind of theoretical framework for how to approach diagnosis, rather than just piece it together by emulating idiosyncratic ways different clinicians like to do things. For example-- how to decide when a constellation of symptoms should be considered together as part of one illness? VS considered separately as simultaneously occurring, discrete disease processes?

This is just personal preference. I suspect other ppl in my same shoes might find the instruction perfectly adequate.

I did find this book, that talks about DDx by symptom, such as "dizziness", "abdominal pain", etc. Anyone read/use this book?

http://www.amazon.com/CURRENT-Medic...LANGE/dp/0071700552/ref=reg_hu-rd_add_1_dp_T2

I wonder if it's worth buying.

If your school provides access to ACCESS MEDICINE, then u may have access to that book.