Make the correct diagnosis by unleashing your inner Columbo

Make the correct diagnosis by unleashing your inner Columbo

You have to forgive me, it’s not me, it’s my mind, it’s very slow, and I have to pin everything down.
-Lieutenant Columbo

With his rumpled raincoat, ever-present cigar, bumbling demeanor and Sherlock Holmesian powers of deduction, disarmingly polite homicide detective Lieutenant Columbo took on some of the most cunning murderers in Los Angeles  most of whom made one fatal, irrevocable mistake: underestimating his investigative genius.

One of my favorite TV shows, and probably my favorite mystery series.  Peter Falk played Columbo, and every episode was a joy.  As the quotes indicate, this show had a recurrent them, Columbo wanted to explain each detail.

In medicine, many great diagnosticians excel when confronted with a diagnosis that does not fit the presentation.  Like Columbo, they match the problem representation (succinct clinical presentation) against the presumed illness script.  They key to these great diagnosticians comes from their outstanding knowledge of illness scripts.  When something does not fit, they wonder whether they need to consider a different illness script.

In a typical Columbo episode, a detail grabs Columbo and will not let go.  He cannot rest until he can explain that detail.

I believe that great diagnosticians use the same technique.  A lab value is not easily explained; a historical feature does not fit the presumed diagnosis; the patient either looks too sick, or not sick enough.

If we want our students and residents to become great diagnosticians, we must teach them about the details that do not fit.  We must consider a different diagnosis than community acquired pneumonia when the symptoms have persisted for 3 weeks despite standard treatment.

So unleash your inner Columbo.  Obsess over the details.  Make the correct diagnosis as correct diagnoses make treatment success more likely.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Suzi Q 38

    You are in the right specialty—Internal Medicine.

    I have a decent one, but he doesn’t do very well when faced with unusual symptoms.

    In February 2011, I had a routine hysterectomy, but afterwards my legs were slightly weak. As I became more mobile and exercised, I got worse.

    No one made the connection, including me, that something was seriously wrong. The gyn/oncologist had no Columbo instinct and he was fearful it was his surgery, so he calmed me down and placated me by saying: “maybe it will go away with time.”

    I finally demanded a neurologist in October, and saw one in November.
    He had NO “Columbo” instinct in him either.

    Ditto for the Gastroenterologist for a year. The reason why I had to see him was that I couldn’t poop without mega laxatives and fiber.

    The PT specialists had a clue with the questionable diagnosis of Cauda Equina, but did not demand a full MRI of all 3 parts of my spine.
    They were afraid to make demands of the neurologist, or to second guess him in any way. They wanted me to do it. When I asked the neurologist about the possibility of that diagnosis, he laughed.

    Let’s see, who else did I have to see.

    I would have left after a year and a half, because I was slowly getting worse, and my legs were getting weaker.

    The gastro finally had the Columbo light bulb turn on and said:
    “Tell me again about what happens when you bend over.”
    Well, the newest symptom when I bent over was a bilateral pull under both arms..puppet string style. I also had numbness in hands and feet for quite some time…almost a year. All the doctors said that the numbness might be due to my A1c of 5.8.

    The gastro of all people had the answer!
    He said that I needed to go to a neurologist right away and have him take an MRI of my upper (cervical ) spine.

    I told him that the neurologist didn’t believe me and my symptoms at all.
    I was ready to go to another teaching hospital anyway. I felt they had had me for a year and a half, and wasted my time and insurance money.
    He insisted that I tell the neuro what he said.

    I did, and the neuro came alive after the gastroenterologist “called him out” on me. Finally someone took a stand against these two incompetent idiots (gyn and the neurologist). He told me to tell the NEURO that I needed an MRI of my UPPER spine, and that He (the Chief of Staff and gastroenterologist) said so.

    When I finally got the news that the MRI showed a severe spinal stenosis, I wept. Not necessarily because of what I had and what I had to face, but because finally, someone, everyone, had to believe me and treat me.

    For a year and a half, the doctors had merely played a game of “hot potato” with my life. No one sat down with a coffee and discussed my care. None of the specialist sat down and talked with each other regarding my care.

    I told the neurologist at my last visit with him that I don’t know what he was doing with me for the last year and a half. I also told him that I don’t know what I would have done if the gastro had not figured out that my problems stemmed from my upper spine. That I was not expecting him to come up with that diagnosis because he was the “poop” doctor. I fully expected this answer to come from him as he was the one in charge of my neurological problems.
    I told him that he had to be a better doctor for others.
    I was not sure of what I was going to do, but I was glad that I got out of his care still being able to walk a little.
    I was not having my surgery done at his facility, because now I did not trust him or anyone else there except for the gastroenterologist.

    I had to leave to get a second opinion and face a possible laminectomy or face M.S.

    With that, I quietly got up and left him sitting there.

  • Suzi Q 38

    Don’t doctors watch “House, M.D.?”

  • Pik Mukherji

    And don’t be certain you’ve made thedx. Considering alternatives requires measured uncertainty. Todays docs do need to be diagnosticians but more and more are testers and “rule-outers.” Fine, but think through what you will do when the test is neg. What’s your alternative?

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