Understanding and improving decisions in clinical medicine (V): Jekyll and Hyde, the two faces of clinical reasoning
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CE - CLINICAL NOTES
Understanding and improving decisions in clinical medicine (V): Jekyll and Hyde, the two faces of clinical reasoning Fabrizio Elia1 · Fabrizio Vallelonga1 · Vincenzo Crupi2 Received: 9 April 2020 / Accepted: 27 April 2020 © Società Italiana di Medicina Interna (SIMI) 2020
“I think there’s little merit in virtue and little blame in mistake” Fabrizio De André: Italian songwriter Mr. A is a handsome 70-year-old man recently returned to Italy after a holiday in East Africa. He is in hospital due to a skin rash accompanied by persistent fever. He has now been hospitalized for a few days, but his case remains unsolved. Many laboratory tests, many instrumental examinations to investigate the presence of the most common as well as the most infrequent aetiologies to possibly explain a febrile rash after a journey in tropical areas. Consistently negative results. Doctors blunder around in the darkness looking for a challenging solution. Dr. Jekyll meets the patient for the first time after a few days’ rest away from the hospital. He is very fascinated by the patient’s journey. Listening to him, he remembers his past work experience in the same places. After a meticulous examination, he asks the nurse to obtain a blood sample to repeat HIV testing. “It is one of the first tests we did, and it was negative,” she replies, somewhat annoyed and surprised that Dr. Jekyll knew so little about his patient’s story. Mr. B is an old hospital acquaintance. He is an addict who heroically survived many years of intravenous heroin. He carries on living on the street and occasionally comes into the Emergency Department complaining of real or alleged aches and begging for the usual dose of analgesics. Nearly one of the family. Once again, he comes back to the hospital for the same reason. A pain in the left hemithorax that he blames on a fall of just a couple of days before. Hyde is the doctor on duty * Fabrizio Elia [email protected] 1
Emergency Medicine, San Giovanni Bosco Hospital, Turin, Italy
Center for Logic, Language, and Cognition, Department of Philosophy and Education, University of Turin, Turin, Italy
2
that day. He has a few words with Mr. B. He finds out that Mr. B is very concerned about his sister, who has recently been diagnosed with breast cancer. He tries to reassure him. He visits him. Nothing of notice. A new chest X-ray is done. Nothing new as compared to the several exams carried out over the past months. He gives him the usual dose of analgesics before moving on to the next patient. At the end of a pretty hard shift, the handover between Doctor Hyde and his colleague is quick and cursory. He almost forgets to mention Mr. B. “Oh yeah, I forgot to tell you: Mr. B. is here again. Same old story. I did not discharge him because he is still in pain. Take care of him”; he points out to his colleague while heading the service exit. Mr. A is rash had not an uncommon explanation. Mr. A actually had an acute HIV infection. The second test, carried out a few days after the first one, was positive
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