There's an entity in medicine that we refer to as gestalt (Although, the word is not specific to medicine, so I suppose anyone can have gestalt about any given topic...). In any case, in medicine, we use it to refer to a physician's ability to quickly eyeball a patient, hear a brief story and and then make a judgement call as to whether the patient is truly sick or not. Of course, we do the tests to confirm, but the gut feeling of gestalt will often dictate how aggressively we hunt down the pathology and how great a priority any particular patient will be during a shift. I think that it is a skill that physicians spend a lifetime honing.
Not surprising then, that barely a year into my clinical experience I occasionally get humbled by patients who I completely miscall. One such patient presented to the emerg on my last shift: Young guy, came in on his own with back and foot pain. Said that the day before, he'd been indulging in the drinks a little to liberally and consequently had fallen. Couldn't really tell us how far or when, but he'd dusted himself off and wandered home.
He was a spirited guy and spent a lot of time bantering back and forth with the staff. His physical exam was pretty normal... some bruising on the foot, but no particular tenderness. His back wasn't tender at all when we pressed on it.
My Gestalt: I figured he'd done some damage to soft tissue and could probably swallow some ibuprofen and be on his way.
In actuality, his scans showed big fractures of the spinal column and 3 fractured foot bones.
Sigh.
Luckily there was no neurological damage, so he will likely recover well from his injuries with some casts and bracing.
The thing about gestalt is that one can't learn it in a book, and not very well from the experience of others. It's a skill that one has to develop by seeing hundreds and thousands of patients: Patients who one has invested some time into, and differentiated before getting any answers. Then, when the final diagnosis returns, whether wrong or right, the case will hopefully be a part of one's clinical acumen. Luckily, thanks to my relative inexperience, every case I see is helping to shape my gestalt. I'm glad I have the opportunity to mis-call a few diagnoses now, as a trainee with a supervisor looking over my shoulder (or under my arm, as is more often the case), before having to make these calls as staff. These cases will stick with me and hopefully make a better clinician in the end.
Ps. You'll notice that most of my anecdotes involve alcohol. It is a plague on the Emergency Department. I can't imagine what the modern ED would look like if alcohol didn't make good people do stupid things... Go easy on the wine this weekend: your body and local emergency physician will thank you.
