{"id":2276,"date":"2012-01-18T11:44:58","date_gmt":"2012-01-18T16:44:58","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=2276"},"modified":"2015-06-04T15:15:08","modified_gmt":"2015-06-04T19:15:08","slug":"id-case-conference-discussant-types","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/id-case-conference-discussant-types\/2012\/01\/18\/","title":{"rendered":"ID Case Conference Discussant Types"},"content":{"rendered":"<p><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/01\/krebs-cycle1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2340 alignright\" title=\"krebs-cycle\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/01\/krebs-cycle1.jpg\" alt=\"\" width=\"290\" height=\"204\" \/><\/a><\/p>\n<p>We specialists in Infectious Diseases love case conferences &#8212; especially those where the case is presented as an &#8220;unknown&#8221;, and we try to figure out the diagnosis from the history.<\/p>\n<p>I suppose this isn&#8217;t very surprising, since ID cases in general are already among the most interesting in all of medicine. Those that are case-conference-worthy are particularly prime.<\/p>\n<p>&#8220;Funny bug in a funny place,&#8221; was how one of my colleagues characterized these cases.<\/p>\n<p>After the case is presented, the discussion by the participants takes various forms. I&#8217;ve been to hundreds of these conferences over the years, and have noted that the path taken by the discussants to arrive at the diagnosis (or not) varies quite a bit. There are certain styles, certain patterns of medical thinking in the conference room (rather than in the exam room or at the bedside) that show up again and again:<\/p>\n<ul>\n<li><strong>The instinctual, &#8220;Here&#8217;s the diagnosis&#8221; approach.<\/strong> Very valuable when spoken by the <em>Giants in the Field<\/em>, who usually have several decades of clinical experience. These are short, targeted discussions that impressively even list the possible diagnoses in order of likelihood.\u00a0<a href=\"http:\/\/www.nytimes.com\/2000\/03\/21\/health\/louis-weinstein-92-infectious-disease-expert.html\" target=\"_blank\">Lou Weinstein<\/a> was the quintessential &#8220;here&#8217;s the diagnosis&#8221; guy; sadly I only got to hear him discuss cases in the last few years of his distinguished career. Not surprisingly, this kind of medical reasoning doesn&#8217;t work nearly as well when attempted by relative beginners, e.g., a medical student, or even a second-year ID fellow. Bottom line: Beware the clinician in his\/her 20s who begins a case discussion with the phrase, &#8220;In my clinical experience &#8230;&#8221;<\/li>\n<li><strong>The comprehensive, &#8220;I&#8217;ve considered the entire universe of living organisms&#8221; approach.<\/strong> Can be both spectacularly interesting and educational or, conversely, crushingly, mind-numbingly boring. <a href=\"http:\/\/www2.massgeneral.org\/medicine\/index.asp?page=residency&amp;subpage=Firm\" target=\"_blank\">Mort Swartz<\/a> (another <em>Giant in the Field<\/em>) discusses cases in this style, and I learn something from Mort every time &#8212; his knowledge not only of ID but all of Internal Medicine is awe-inspiring. However, my heart always sinks when a mere non-Mort mortal (couldn&#8217;t resist) starts a discussion by listing <em>all<\/em> the main categories of microorganisms as a prelude: \u00a0&#8220;Let&#8217;s see, as potential causes for this person&#8217;s infected hip, there are prions, viruses, aerobic and anaerobic bacteria, higher bacteria, mycobacteria, fungi, algae, protozoa, helminths, ectoparasites &#8230;&#8221; Time to get some more coffee.<\/li>\n<li><strong>The prodding, &#8220;Let&#8217;s stop this game and tell me the diagnosis&#8221; approach<\/strong>. Usually goes something like this: A generic case is presented with minimal information &#8212; let&#8217;s say a man with a skin infection. No further history is given. And the discussant, not surprisingly, prods the presenter to give more information. &#8220;Any cats?&#8221; he\/she asks, thinking <em>Pasturella multocida <\/em>or bartonella. &#8220;Any water exposure?&#8221; thinking <em>Aeromonas hydrophila <\/em>or <em>Vibrio vulnificus<\/em>. Because the discussant <em>knows<\/em> a simple skin infection is <em>never<\/em> going to make it to case conference, he\/she keeps searching &#8212; there MUST be something interesting about the epidemiology. The presenter relents: &#8220;Well, as it turns out, the patient works as a clam shucker.&#8221; Bingo, <em>Mycobacterium marinum <\/em><em>or <em>Erysipelothrix rhusiopathiae<\/em><\/em><em>. <\/em><\/li>\n<li><strong>The diverting &#8220;I don&#8217;t know what this diagnosis is, but I certainly know a lot about other stuff, so let&#8217;s talk about that&#8221; approach. <\/strong>This clever strategy usually involves a true expert in a field forced out of his or her comfort zone. The world expert on salmonella, for example, suddenly finds him\/herself discussing a hospital-acquired pneumonia in a patient who&#8217;s just had cardiac surgery. You can be sure that eventually the subject of intracellular pathogens (of which salmonella is an <em>excellent <\/em>example) will come up &#8212; somehow.<\/li>\n<li><strong>The deer in a headlights, &#8220;You talking to me?&#8221; approach. <\/strong>Happens frequently when someone gets called on to discuss a case who&#8217;s not expecting it. Perhaps they&#8217;re junior faculty. Or just shy. Or maybe their mind has wandered, and they&#8217;re thinking about the Patriots&#8217; playoff game, or whether to have another muffin, or the Krebs cycle. (I have never spontaneously thought about the Krebs cycle &#8212; see Figure above for a refresher.) And I&#8217;ve been informed by one of my most esteemed colleagues that some people just hate being called on, which I totally respect. (But others love yacking away during conference &#8212; they get offended if they&#8217;re not asked to opine &#8212; so it would be helpful to know how people feel about this. A green sticker on your white coat, perhaps, one that reads, &#8220;CALL ON ME!&#8221;) Suffice to say the startled discussant rarely gets the diagnosis correct, but they are often inadvertently\u00a0funny.<\/li>\n<\/ul>\n<p>Here&#8217;s a tip &#8212; if you&#8217;re ever asked about a case during conference, and you haven&#8217;t been listening, and the person being discussed is acutely ill, just say, &#8220;It could be staph.&#8221; If chronically ill, &#8220;It could be TB.&#8221; You will never be wrong.<\/p>\n<p>What kind of discussant are you?<\/p>\n","protected":false},"excerpt":{"rendered":"<p>We specialists in Infectious Diseases love case conferences &#8212; especially those where the case is presented as an &#8220;unknown&#8221;, and we try to figure out the diagnosis from the history. I suppose this isn&#8217;t very surprising, since ID cases in general are already among the most interesting in all of medicine. Those that are case-conference-worthy [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,6,8],"tags":[149,498,595],"class_list":["post-2276","post","type-post","status-publish","format-standard","hentry","category-health-care","category-infectious-diseases","category-medical-education","category-patient-care","tag-case-conference","tag-infectious-diseases","tag-medical-education-2"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/2276","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=2276"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/2276\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=2276"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=2276"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=2276"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}