Chess and Combat: The in Medicine

Algorithm

inception with the Cabot cases (now published as clinicopathologic cases from Massachusetts General Hospital in the New England Journal of Medicine), physicians have learned from clinicopathologic cases (1) how mistaken a clinical diagnosis can be and (2) that the pathologist has the last word. The calm of the morgue is far different from the hurly-burly of the

New Requirements for Authors.—Congress recently passed The Copyright Revision Act of 1976 which affects JAMA's procedures for acceptance of manuscripts. Please

refer to the "Instructions for Authors" page for details.

From their

clinic, and clinicians need

thologists' judgments laboratory.

not feel the same reverence for the pawhen confrontation occurs in the clini-

cal

This issue of The Journal (p 2709) offers an algorithm for the diagnosis of anemia and an example of its application to determine if the laboratory was properly or improperly used. It is a simplistic schema that provides, on the basis of hemoglobin concentration and a computation of average RBC size, a recipe for the workup of anemia. On their procrustean bed, the authors placed charts of 258 consecutive cases of anemia. In 11%, it turns out, the laboratory was overused. Tests had been or¬ dered that were not indicated. In 24%, the laboratory was under¬ used. Five percent were scored as a mixture of underuse and overuse.

The bottom line, the take-home message, is that the labora¬ tory is often improperly used in the workup of anemia. No doubt of that. But is an algorithm a proper way to establish our inadequacies? This one, for example, has several deficiencies. Some hematologists, for example, believe that the reticulocyte count is a good, cheap, initial diagnostic cut to use in every case of anemia: it separates high-output anemias from low-output anemias. In this algorithm a reticulocyte count would be scored as overuse in every microcytic anemia, even though the test can, for example, separate hemoglobinopathies from iron deficiency anemia. Here is another questionable requirement: in every case of macrocytic anemia with a low reticulocyte count serum B12 and folate determination must be done on pain of penalty for under¬ use. Surely a look at a blood smear would not be amiss before ordering those costly tests. It is worthy to note that the al¬ gorithm does not even consider the blood smear as a part of the initial workup of anemia, even though abnormal WBCs and a variety of poikilocytic RBCs can give in a minute the diagnosis of many kinds of anemia. Of the cases adequately followed up, 29 were scored for overuse: in addition to the approved tests that the physicians

Address editorial communications to the

Editor,

535 N Dearborn

others were done that were deemed inappropriate. of these cases were found to have iron defi¬ three However, the basis of unallowable tests for serum iron anemia on ciency level and iron-binding capacity. Thus it turned out that 10% of 29 unsolved cases were solved by a cheap but proscribed proce¬ dure. Should we not pause to consider the validity of that pro¬ scription? We might also ask if the mandatory B12 determina¬ tions solved 10% of the cases of macrocytic anemia. Algorithms are to the practice of medicine as chess is to war, but with a difference: we can get hurt when results of the al¬ gorithm game are extrapolated into real life. When used as a teaching device, algorithms may provide students with ill-con¬ ceived or even dangerous simplifications. Furthermore, the al¬ gorithm is easily adapted to computer practice. Taken seriously by a looming bureaucracy, our algorithm might make its mark on American medicine by instructing us to order B12 analysis and forbidding serum iron analysis on the basis of one person's conception of how to play a game. "An application of this general approach to the anemia workup would be to have the clinical laboratory offer a test called 'complete blood cell count with follow-up.' If a low hemo¬ globin value were detected, an algorithm such as the one pre¬ sented in Fig 1 would be followed." It is a small step from "offer" to "provide." It is another small step from "provide" to "require." And all of this would fi¬ nally be enforced with the clout of Medicare. Be alert. The first sproutings of this bureaucratic liana may be no farther away than your own clinical laboratory. William H. Crosby, MD had

ordered,

Scripps Clinic & La Jolla, Calif

Holmes

or

Research Foundation

Spade?

patient, an illness is a dramatic, often tragic chapter in a long autobiography. To the diagnostician, however, it is

To the

primarily a mystery story in which he is the detective. As such, he may wish to draw some parallels from the behavior of his

St, Chicago 60610

Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 06/18/2015

counterpart, the

professional sleuth of popular fiction.

essay, the master dichotomist C. P. Snow' classified detective stories into two species, the classical and the romantic. In the former, the detective solves his problem by deductions based on observation and logic, much as the scientist solves his by the scientific process. Curious, observant, and impeccably logical, he does not indulge in psychological analysis, nor does he display any emotional involvement, let alone righteous indignation. His satisfaction, as well as that of the reader, comes from solving a mystery, from bringing order into a disorderly situation. This type of detective was predominant in the mystery stories pioneered by Edgar Allan Poe and Sir Arthur Conan Doyle and featured in a host of other "classical" whodunits that proliferated until about the late 1920s, when the "roman¬ tic" type of detective story began to supplant it. The latter's hero, the independent, idiosyncratic, intensely emotional private eye, so brilliantly depicted by Dashiell Hammett, is unpredict¬ able, intuitive, and prone to bypassing or ignoring conventional methods of investigation. "Plunging into the musk of myste¬ rious crime," he is more concerned with helping the aggrieved and punishing the guilty than with attaining a neat solution to a In

a

recent

mystery. Can the medical diagnostician be similarly cast into the classical or romantic mold? We may recognize the cool, astute, classical diagnostician, whose deductive rigor dazzles the students at ward rounds and clinical-pathological conferences, where in the manner of a Hercule Poirot assembling all suspects and dismissing them one after another before pinpointing the culprit, he sifts the possible and probable diagnoses, until, all red herrings disposed of, he arrives at the right diagnosis by a brilliant coup de force. We may also recognize him in a court of law, where defending himself in a malpractice suit, he skillfully refutes all accusations by unrav¬ eling the skein of logical deduction before the judge and

jury.

As contrasted with the classical diagnostician, his romantic counterpart is recognizable by his impatience, impulsiveness, intuitive improvisations, and penchant for cutting corners and experimenting with therapeutic trials. Diagnosis to him is less of an exercise in logic than a process of getting to know the patient and his problems, so as to get on quickly with treatment. He does not shine at ward rounds and clinicalpathological conferences. Nor does he sparkle in court. To his patients, however, he is the personal physician par excellence, a true practitioner of the art of medicine. Having sharply dichotomized the fictional detective, C. P. Snow comments: "It doesn't need saying, or it ought not to, that no serious investigation of crime has followed either of Real police work has not yet been these two paper patterns. satisfactorily conveyed in fiction." Have we been carried away by an oversimplified metaphor based on fiction? Is real medical detection truly represented by the two types? We can readily think, for example, of a third type, the technological diagnostician or, as Burch2 chooses to call him, the medical technocrat who is more at home with computers, scanners, and fiber optic instruments than with .

.

.

history our

physical examinations. Do the classical and diagnosticians really exist? No matter. They exist in

and

romantic

memories, in

often than not, 1. Snow CP:

our

they

imaginations, in our coexist in ourselves.

nostalgias, and

more

Samuel Vaisrub, MD Keylor WR (eds): New York, Harper & Row

The classical detective story, in Weiner DB,

Parnassus Essays in Honor of Jacques Bargan. Publishers Inc, 1977, p 16. 2. Burch GE: Technocrats or doctors? Am Heart J 94:1-2, 1977.

Even Common Diseases Can Be

Complex

of the fact that illness is not a matter injury, a neoplasm, or a metabolic disjust order, but of a combination of factors, not the least important of which may be life-style or behavior. Unless the multiple factors underlying an illness are recognized, the diagnosis may be missed or the treatment fail. Such a situation is described in the CLINICAL NOTE in this issue of The Journal (p 2718). Fiumara's account of diagnosing gonococcal proctitis in a married woman illustrates once more that the practice of medicine is as much an art as it is a science, and that the securing of a complete and detailed history is an important part of that art. The time constraints of medical practice frequently pressure us into making a hurried diagnosis or instituting a routine form of treatment. Although this approach may suffice for most, it is not adequate for the difficult or unusual case. This fact is brought out by the style of Fiumara's report in which he dwells not on the values reported from laboratory tests, but rather de¬ scribes the patients' attitudes, answers to questions, and reac¬ tions to the taking of a detailed sexual history. The case history unfolds here as it does in our own consulting rooms, and we perceive the problem from the history rather than from the findings of examinations. Although most diagnoses are made in this fashion, most reports to journals are made quite differently. Much of what we publish in The Journal makes the physician appear as just one more device in a chain of gadgets that record, store, and then spew forth information on command. This re¬ port makes medicine seem both interesting and fun. We are also reminded that what may be adequate chemother¬ apy for gonococcal infection of some sites can be ineffective therapy for the same infection in other sites. The gonococcus in the male urethra is exposed to concentrations of drug in the urine in addition to a systemic exposure via the plasma level. However, the organisms in crypts of rectal mucosa or in joint fluid may effectively be protected against some drugs in doses that might otherwise be effective. Although a longer course of

Frequently of

an

penicillin

we

lose

sight

infection,

G

an

procaine given intramuscularly

at a

higher dosage

in the case cited, a 4-g dose of did the job just as well and with spectinomycin hydrochloride greater convenience. Perhaps the existence of these chemotherapeutic wonder drugs contributes to the sexual permissiveness and behavior pattern described in this article. Because pre¬ vention is better than cure, then perhaps physicians should ad¬

would have solved the

vocate a return to a

real infection-the

problem

relatively simple prophylaxis against vene¬ of a condom for sex outside of marriage.

use

Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 06/18/2015

William R.

Barclay, MD