Great reminder for physicians on common cognitive errors and how to avoid them as much as possible. The theme of trying to attach a diagnosis to a patient that doesn't quite fit, often based on their demographics or what is 'most likely' is reiterated throughout the book. Of course common conditions can present in uncommon ways, but the emphasis on trying to reach a diagnosis right away opens up the risk of missing something important - one example cited aortic dissection misdiagnosed as musculoskeletal pain and another a compression fracture that turned out to be cancer in a young boy. While these examples are extreme they are certainly not unheard of. Another was overreliance on clinical algorithms which resonated with me.
As a neurology resident we commonly evaluate patients with suspected stroke and grade the severity based on several exam findings which together make up the NIH stroke scale. This score helps determine whether to administer a clot busting drug called tpa, which can decrease the disability caused by a stroke but comes with a nontrivial risk of bleeding, both systemically and in the brain. While a high score indicates a severe stroke (or some other global process mimicking a stroke), a low score can be deceptive, as even a low score can indicate significant disability. For example, one patient working in a very cognitively demanding field had intact motor function and speech but was unable to accurately calculate even simple equations. His score was 1 (the highest score is 32). While some may argue that the patient had a low score, without treatment he would not have been able to continue his career- a large consequence for someone in their prime. The decision was made to give the patient the drug, and the next day his Mri indeed showed small strokes in a part of the brain important in solving calculations. He had no residual symptoms, and no untoward side effects from the drug. The idea of treating each patient as an individual is thus emphasized.
Another point made in the book was not to prematurely write a symptom off as being psychological. I once admitted a patient with acute onset of altered mentation and agitated behavior who had recently lost their family member. The family had reiterated that the loss was a month ago and that up until a few days prior to coming into the hospital the patient had been completely normal with the exception of some normal grief. She had gone to another hospital prior who felt that this may have been psychological, as the patient had imaging that turned out normal and labs which showed no drug ingestion. I admitted that while I had some ideas for what may be causing it, we would need further testing to confirm. An eeg showed a pattern consistent with encephalitis and the patient was found to have suspected autoimmune encephalitis, which presents with very bizarre neuropsychiatric symptoms (read the book Brain on Fire if interested). She responded beautifully to a course of treatment that dampened the immune system's abnormal response.
Of course there are the misses too- a time that I once thought a brain wave test on a child with autism and tics signified seizures, but in retrospect was artifact from repetitive hand movements the child was making.
Overall, I loved this book. While the information presented is going to be familiar to most physicians, it will make you think critically about your practice behaviors and how to improve upon them, as well as the limitations of medicine.
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