If you know what it’s not, is it ok to not know what it is? #WILTW

This is the 142nd #WILTW

A virus is an infective agent that typically consists of a nucleic acid molecule in a protein coat, is too small to be seen by light microscopy, and is able to multiply only within the living cells of a host.

Making a definitive diagnosis of having a viral infection is technically difficult. While there are rapid detection tests for specific viruses which aid in decision making about cohorting patients or prescribing treatments, those which cause colds and sore throats need long winded and expensive processes. However one of the most common diagnoses in paediatrics is that of a ‘viral’ illness. Special tests aren’t needed – just a good history and examination.  The child who presents with a fever, runny nose, a bit off their food and has a red throat or pink ears is likely to have a virus. Knowing the specific name of the virus is essentially redundant because the natural history of the disease is so predictable.

That is of course if it is a virus; the consequences of making an incorrect judgement on this are devastating.

Living with uncertainty is a fundamental part of a health care professional’s practice. But it isn’t easy. I can rarely be truly certain in my diagnosis of a virus. I can be very confident, I can give appropriate safety net advice and, most importantly, I can gain the understanding and trust of the family. If I can’t do these things and the risk of a more serious illness outweighs, in any way, my belief that this is a viral illness then more observations and investigations are likely to be required.

I was speaking at a patient safety conference this week on how scoring systems (sometimes known as Early Warning Systems or EWS) can be utilised as educational tools. Assisting, especially junior staff, in reducing diagnostic uncertainty regarding the level of a patients acuity is one method by which they are beneficial.

However it should never be a purpose of a scoring tool to make a diagnosis and they will never reduce uncertainty to zero. There was a powerful piece on this in the New England Journal of Medicine last year.

Our protocols and checklists emphasize the black-and-white aspects of medicine. Doctors often fear that by expressing uncertainty, they will project ignorance to patients and colleagues, so they internalize and mask it. We are still strongly influenced by a rationalist tradition that seeks to provide a world of apparent security.” (Simpkin & Schwartzstein N Engl J Med 2016; 375:1713-1715)

Uncertainty can be seen as a sign of weakness but acknowledging it may well reduce cognitive biases. By being uncertain you are more likely to be considering what disease processes may be present – the current emphasis on sepsis an example of a diagnosis that isn’t being considered often enough.

Ultimately the diagnostic label given when you discharge a patient is of little value if you have got the diagnosis wrong. For some paediatric presentations it may well be far more important to be satisfied you know what it isn’t and have adequately reassured the parent and/or carer that that is the case.

What have you learnt this week? #WILTW

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