Premature closure and the importance of a differential diagnosis #TPSER8

By Barbara C. Nzegwu, M3
The University of Toledo College of Medicine

The first day of the telluride roundtable was filled with great introduction into the great discussions that we would be having the rest of the week. We started with the story of 15 year old Lewis Blackman and how he lost his life due to a costly mistake and inattentiveness made by  his medical team. This was a powerful story to me not only because his mother, Helen Haskell, was among us sitting just two rows ahead of me, but also because as the story was being told, I was able to pick up on what the diagnosis of a perforation with the symptoms of an acute abdomen as the movie told his story.  And I only have a third year medical student education.  I felt the injustice and the less than standard of care that Lewis and his family had received. One of the objectives of the movie was to understand the term premature closure and to recognize when we are doing it in medical practice. To me the term premature closure means that one doesn’t take time to go through a differential diagnosis. It means that doctors, residents, students become so set in their thoughts, mindsets, ways that we think that once we’ve come up with what we think the diagnosis is, then we can never be wrong. I remember learning the concept of differential diagnosis in my 1st and 2nd years of medical school. I was not particularly fond of it because I always thought it took too much time. I remember thinking, “Why do I need another diagnosis when this presentation is so classic, it can only be just this one answer?” It was during my third year of medical school that the concept became so invaluable to me in regards to the chief complaints of my patients.  Once a differential diagnosis is set, then the process of ruling out can occur. And this occurs by lab tests and imaging in conjunction with revisiting the key items from the history and physical. The fact that Lewis didn’t have any such process conducted throughout the course of his medical care is injustice and is not the standard of care. I sincerely pray to God that as I continue with my medical education and even when I begin my practice, that I never adopt a practice of premature closure and that I will always practice going through a differential.