Would you correct physicians you work for?

[curlycorday]

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Hi all,
I'm just an MSI doing a Peds clerkship as prescribed by my medical school. Today we admitted a 17 month old male with 'massive splenomegaly' extending to his pelvis, thrombocytopenia (77), neutropenia (ANC=250), hepatomegaly, failure to thrive (in 5th percentage), originally complaining of a low grade fever of unknown origin. (I thought this case would be interesting since many of us probably won't see it again). Anyway, the pediatrician I work with referred him to a peds hem/onc thinking that he had leukemia, and that was his admitting diagnosis (with no further bone marrow or splenic tests). I happened to do a paper on lysosomal storage diseases (Gaucher (beta acid glycosidase deficiency), Niemann-Pick) and I think he fits the criteria perfectly. The ped. I work with dismissed the idea, saying "only jewish people get this..." (the child is of japanese descent). So, I plan to bring it up at a conference on Friday and I am wondering if anyone has dealt with a similar sort of situation, and could help me find the words gracefully to suggest it at the meeting.
Thanks

 

[tkim]

Unless you think this patient's life is in imminent danger, you should avoid openly contradicting your attending in front of other people.

In a perfect world, your attending would take into account your background and perhaps entertain your diagnosis, and not take it personally if he were wrong.

It's not a perfect world.

I'd advise letting the heme/onc consult support or refute the admission diagnosis and perhaps then reintroduce your theory.

 

[silas2642]

I would keep my big mouth shut if I were you-- you are a lowly MSI and he is an attending physician. I think that in many ways you have to take in faith that he knows a helluva a lot more than you, and even if he's wrong the patient is his responsibiltiy, not yours. I wouldn't say anything else, man. The last thing you need is an attending thinking that you're an arrogant med student; he's just going to wind up pounding you later with his superior knowledge and experience.

 

[Law2Doc]

Hi all,
I'm just an MSI doing a Peds clerkship as prescribed by my medical school. Today we admitted a 17 month old male with 'massive splenomegaly' extending to his pelvis, thrombocytopenia (77), neutropenia (ANC=250), hepatomegaly, failure to thrive (in 5th percentage), originally complaining of a low grade fever of unknown origin. (I thought this case would be interesting since many of us probably won't see it again). Anyway, the pediatrician I work with referred him to a peds hem/onc thinking that he had leukemia, and that was his admitting diagnosis (with no further bone marrow or splenic tests). I happened to do a paper on lysosomal storage diseases (Gaucher (beta acid glycosidase deficiency), Niemann-Pick) and I think he fits the criteria perfectly. The ped. I work with dismissed the idea, saying "only jewish people get this..." (the child is of japanese descent). So, I plan to bring it up at a conference on Friday and I am wondering if anyone has dealt with a similar sort of situation, and could help me find the words gracefully to suggest it at the meeting.
Thanks

You don't want to be seen as disputing your superiors. You probably should take another run at your ped, with a relevant article in hand, and suggest that after doing a bit more research you think perhaps this diagnosis shouldn't be totally dismissed from the differential. And then keep quiet. He may still ignore you, but at least then, if others at the conference suggest the same thing, your intelligence will improve in the ped's eyes and he will give you more credence the next time.

 

[njbmd]

Hi all,
I'm just an MSI doing a Peds clerkship as prescribed by my medical school. Today we admitted a 17 month old male with 'massive splenomegaly' extending to his pelvis, thrombocytopenia (77), neutropenia (ANC=250), hepatomegaly, failure to thrive (in 5th percentage), originally complaining of a low grade fever of unknown origin. (I thought this case would be interesting since many of us probably won't see it again). Anyway, the pediatrician I work with referred him to a peds hem/onc thinking that he had leukemia, and that was his admitting diagnosis (with no further bone marrow or splenic tests). I happened to do a paper on lysosomal storage diseases (Gaucher (beta acid glycosidase deficiency), Niemann-Pick) and I think he fits the criteria perfectly. The ped. I work with dismissed the idea, saying "only jewish people get this..." (the child is of japanese descent). So, I plan to bring it up at a conference on Friday and I am wondering if anyone has dealt with a similar sort of situation, and could help me find the words gracefully to suggest it at the meeting.
Thanks

Hi there,
First of all, you are NOT correcting your attending physician, you are offereing another diagnosis in the differential. Second, as an attending physician, I would have walked you through my decision-making precess and explained why I wanted the hem-onc referral in my differential. Third, nothing prevents you from following along with this patient as the hem/onc person goes through the work-up. You may actually learn something. And finally, doing a paper DOES NOT make you an expert on a particular disease or subject.

njbmd 🙂

 

[chrisjohn]

*** or if you're me KFMS.

 

[curlycorday]

*** or if you're me KFMS.

Thanks all, I'm glad I asked. I realize that I am by no means an expert in metabolic disorders, it was just never included in a differential of any kind. Good advice

 

[tkim]

It may very well be that since you know more about GD and NP you'll naturally diagnose that more often, or it will creep up your differential when it really shouldn't.

If you have access to your school's uptodate.com website, you should look up the article for evaluating pediatric splenomegaly. The storage diseases are there - just lower on the differential. Horses, not zebras.

If you want, I can email you the article. Just PM me with your email addy.