ABCDE…X – hierarchy and lost opportunities

The accumulated knowledge within a typical medical ‘firm’ is great, but the way a typical firm functions may not allow much of that knowledge to see the light of day. If all the decisions made by that peculiar monster originate from its ‘head’  – the consultant – opportunities can be lost.

The situations described below are based on examples that I have observed or been part of. The contrast between them serves as a lesson.

I have described the symptoms and signs in generic terms such as A, B and C, with a diagnosis X, because I do not wish to describe the specifics. The educational value of the piece might be greater if I had stuck to reality, but in this case I wished to avoid giving medical details.


The patient presented on day 1 with symptom A. The admitting doctors didn’t have a clue what the diagnosis was. The patient was transferred to my ward. I saw her on day 2, and an investigation showed abnormality B. A and B did not connect in my mind – the diagnosis was still not clear. I dictated a broad differential diagnosis centred on common and not so common conditions, and I gave instructions that various investigations should be arranged to narrow it down. Time was short; we moved on.

On day 3 I was told that the patient was reporting symptom C, and that the patient was worse. I went to see her, and detected sign D.

A, B, C and D. It still didn’t make sense. A strange collection of symptoms, signs and findings. The Foundation Year doctor I was with looked worried, because the family had been asking why their mother was not improving. The SHO came onto the ward. I asked about the results of the investigations that had been requested, and rather embarrassedly the two trainees told me that only three of them had been completed. Others were ‘in the system’.

We had a conversation about how to prioritise tests and persuade radiologists…we talked about getting the most out of the system. We didn’t talk about the patient. The differential diagnosis remained unmodified. The juniors set off to do their best.

On day 4 I saw her again. She had deteriorated further. We waited for some more results. Overnight she was seen by the on-call team, as she had suddenly begun to display a florid example of sign E. The new, crucial development completed the picture and led to a new diagnosis. A specialist opinion was requested first thing, and when I saw that specialist in the corridor during the day she told me about the ‘classic features’ of disease X. But it was probably too late now. The patient was on the way to intensive care.

I looked up disease X on the computer and saw how, in this condition that I had not personally encountered before (but one I had read about during my studied) symptom A – accompanied by abnormality B – proceeds to symptom C, followed a day or two later by sign D, and in latter stages evolves into sign E… by which time the disease has often progressed too far to be salvaged.

Another day, another way…

The patient presented with symptom A. The admitting team did not know what cause was, but they had a few ideas. On the next ward round an abnormality in laboratory parameter B was noted, but it still didn’t add up to anything in particular. Various tests were requested, and a referral made to specialist M (mainly because they were used to seeing patients with multi-system, i.e. frequently baffling, disorders).

The patient did not do well on the initial treatment regimen, and on day 3 was seen again by the consultant. This time the patient described symptom C. The junior doctors stood at the end of the bed looking worried, still uncomfortable when faced with deteriorating patients due to unexplained disease. Time was pressing, there are many more patients to see. Further investigations came to mind, but they were not guided by an idea. It was diagnosis by ‘shotgun’  – multiple simultaneous tests arranged in the hope that one of them hit something.

The consultant worried that he didn’t know what was going on, but reassured himself that all of the sensible things were being done. The team moved away from the bed. Then the consultant turned around, and took them to one side.

“What do you think?” he asked of them.

“What do you mean?”

“Well what do you make of these symptoms, these abnormalities. Do they ring any bells with you?”

“Er…not really.”

“Well have you seen a patient with anything like this before? Anything similar? Anything!?”

“A couple, but nothing that really looks like this. There was one case…”

“Tell me about it!”

“He didn’t behave like this. The patient was much younger. But they went on to develop symptom E, and I remember they went to intensive care. I was a student then. It was, I can’t remember the diagnosis, something to do with…system Y.”

The consultant paused. That category of disease had not crossed his mind. Could it be that? Could it be?

He went to the computer. A bell began to ring faintly in his mind. Something from the early days of his training. He googled (everbody does) the system mentioned, and added symptom A. He clicked on a link to Pubmed. And there it was. Disease X, a severe manifestation of system Y dysfunction. It starts with symptom A, is associated with abnormalities in parameter B, often leads to symptom C, usually progresses to display sign D, and at that stage you have to give treatment Z before sign E kicks in. Could it be that?

“Let’s get the specialist. It’s a small chance, but if it is that she needs treatment today.”


On the face of it these examples demonstrate something simple. If you spend time reflecting on a difficult diagnosis and keep an open mind to new data you might happen upon something that pushes you in the right direction. Don’t commit yourself to the initial plan, don’t be wedded to the first thought. That’s just good medicine.

But there is also a lesson about leadership on the ward.

As one progresses through a medical career one’s breadth of view contracts. Most hospital consultants are also specialists in something, and the demands of the specialty can leave little room for refreshing one’s knowledge of the rare and exotic. However,  the temptation to allow the consultant to embody the entire experience and expertise of the team is great. Junior doctors are meek, especially early on in the training, and will not readily challenge the differential diagnoses or management plans put forward by the consultant. Often (always!) they will be having independent thoughts as to what might be going on with the patient, but only a proportion of those thoughts will be voiced. Bits of knowledge, recollections, ringing bells from their own experience are ignored or put to one side as the momentum of the consultant’s diagnosis generating, management planning juggernaut rolls on. If they are clearly in a hurry, they are even less likely to be slowed down or interrupted by a trainee.

Sometimes the hierarchy needs to be flattened, albeit temporarily, to allow the views of each team member to be aired and enlarged upon. It’s not a revolutionary concept, but in hospital medicine, which remains hierarchical by virtue of the need to remain highly efficient in a continuously pressurised environment, the luxury of slowing down and allowing new ideas to germinate can be lost.


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