I suppose it could be the case that a simple decision-tree could have produced the result in question. What I doubt is that, when a patient who has already had 2 valve replacements presents with fatigue, dyspnea, and weight loss, the heart wouldn't be the first thing to check, on anyone's decision-tree. And on top of that, he came back 2 months later with the same symptoms and still no little light bulb went on "Oh! His heart!" 

I mean, even if the primary physician had not been involved in the situation 4 years previously, you'd think that, perhaps when using a stethoscope, one might notice the big SCAR on the patient's chest, and ask about it. Or take a history. Or read the history taken by someone else.

Sheila Thomas
Librarian
Delaware Academy of Medicine
Newark, DE
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-----Original Message-----
From: Medical Libraries Discussion List on behalf of Donna Beales
Sent: Wed 2/14/2007 10:23 AM
To: [log in to unmask]
Subject: Re: CHAT: From this week's New England Journal of Medicine
 
This posting has raised an issue that has been in my mind for some time.

It sounds very much like the patient's doctor was following standard clinical advice offered in a resource like UpToDate or Cochrane, name your favorite encyclopedia-style online resource.  

Medicine seems quite willingly to have adopted a one-size-fits-all approach to the treatment of patients.  We call this by various names, evidence-based medicine, clinical guidelines, standards of care etc. etc.  

While I don't disagree that these tools are essential, they are not always adequate.  They're systems thinking models.  As part of the computer age we're used to thinking in binary terms-- if/then statements, and algorithms. if A=X, then go to B. If A=Y then go to D.

Leaving aside a recent article in BMJ stating that US guidelines are heavily influenced by industry, IMO the problem arises when the answer to the algorithm is "none of the above."  The "zebras" of medicine throw the system right out the window.  

Doctors seem to do very well with the norm, but do less well when the case falls outside the box.  They're taught to think horses, not zebras, and so they do.

I hope to publish on this issue.

Donna L. Beales, MLIS
Lowell General Hospital
Health Science Library
295 Varnum Ave.
Lowell, MA 01854
978-937-6247
Fax: 978-937-6855
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www.lowellgeneral.org/library