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Sir,I am concerned about some of the case presentations which have appeared in your self-assessment section recently, as they seem to me to exemplify a very old-fashioned attitude to differential diagnosis and one which, frankly, we should have abandoned many years ago. I refer specifically to the papers by Balcombe1 and by Usalan and Özarslan.2 In the first paper we are asked: “What is the cause of thrombocytopaenia?”. The answer given on the next page begins by providing a box with a long list of potential causes of a low platelet count, most of which are irrelevant to the case in question. Surely the question that should be asked and discussed is: “What are the most likely causes of thrombocytopaenia in this patient?”.
In the second case the differential diagnosis places adrenal crisis as the third potential cause of the patient's illness; given the clinical features described it should surely have been placed first, or at least second. The authors then report that they performed a rapid ACTH test before starting treatment. If a patient is as ill as this lady was and adrenal crisis is suspected there is no need to do a rapid ACTH test in the early phase of the illness: all that is required is to take a blood sample for later analysis for cortisol. Treatment should then be started immediately. Provocative ACTH testing can be done at a later date if necessary. Usalan and Özarslan go on to give a description of the potential causes of an adrenal crisis (box 2), but do not include the most likely cause in their patient, ie, that the patient had subacute or chronic, mild adrenal insufficiency which became critical as a result of her pregnancy and urinary infection.
It seems to me that both reports are examples of ‘doing medicine by the book’. Over the years we have all met junior doctors whose book knowledge is impressive but who cannot apply that knowledge effectively in clinical practice, cannot prioritise and cannot act decisively and effectively when faced with a serious medical emergency. Should we not be laying much more emphasis on clinical problem solving in a ‘real-world’ fashion and less on the learning of long and often irrelevant lists?
Response from the Editor:
The Editor and Editorial Board have shared similar anxieties. For this reason we plan to develop a more ‘commissioned’ approach to self-assessment questions. In future, authors will be requested to only submit cases with a clear educational value, and to discuss the background to the case more fully. It is hoped that such cases will slowly replace the current type of self-assessment questions, and that they may also open up a forum for other clinicians to give a commentary on the case.