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Covfefe and the art of the diagnostic deal

DII small banner By Warren R. Heymann, MD
June 2, 2017

progressive nodular histiocytosis
Progressive nodular histiocytosis. A, Multiple papulonodular lesions over upper extremities and trunk. B, Leonine appearance for coalescing of lesions on face.
Credit: JAAD

I don’t know what’s more frightening — making diagnoses on autopilot or being genuinely stumped and having to think like a first-year resident.

The crux of being a physician is the ability to make an accurate diagnosis. The importance of placing the right label on a patient cannot be overestimated, because all therapeutic and management decisions stem from the diagnosis. Two things happen once a diagnosis is rendered — 1) other physicians assume that the diagnosis is correct, basing their therapeutic decisions on the diagnosis and 2) the diagnosis sticks like “krazy glue” in the patients record — trying to get the medical record correct takes Herculean effort.
Trimble and Hamilton note that the essence of all medical practice revolves around three questions: 1) “What is the problem?” [diagnosis]; 2) “What are the possible solutions?” [therapies/management] and 3) “What is the best solution for this patient?” Looking at the diagnostic process in detail focuses on information gathering, hypothesis generation, hypothesis testing, and reflection. This is of utmost importance as diagnostic errors may account for 17% of all adverse events (1).

According to Croskerry and Nimmo, “there are two distinct modes of thinking, each of which has distinctive properties. Intuitive reasoning is characterised by the ‘shoot-from- the-hip approach,’ or ‘gut reaction.’ It is fast, impulsive, effortless, reflexive, multi-channelled and may serve us well in certain situations in medicine, but it is error-prone. Analytical reasoning, by contrast, is slow, explicit, deliberate, purposeful, single-channelled and generally more reliable.” (2)
As dermatologists, we are especially skilled at pattern recognition and morphology of skin lesions. Diagnoses are made almost instantaneously for most patients. (“Dr. Heymann, how can you diagnose that so quickly?” I am often asked. Patients understand what I mean with my slightly snarky reply, “How long does it take for you to recognize your mother?”) With experience, we increasingly get through our days with a “gut reaction”, akin to the phenomenon detailed in Malcolm Gladwell’s book, Blink: The Power of Thinking Without Thinking. The key, of course, is recognizing when that approach is inadequate — when our trained eyes recognize that something is amiss — that is the time to shift gears to the more deliberative approach.

Earlier this week, I saw a man in his late 50s who presented with lesions that have been increasing in number over the past 25 years on his face, trunk, and extremities (see image). Many lesions were excised and recurred. Clinically they were keloidal, but most importantly, I recognized that I had never seen anything like this before. Careful analysis had to prevail, elaborating a differential diagnosis including infections (keloidal blastomycosis), dermatofibrosarcoma protuberans, tuberous xanthomas, and xanthogranulomas. I brought in my partner Justin Green to examine him — we were bantering about the diagnostic possibilities and he considered progressive nodular histiocytosis (PNH). The biopsy demonstrated xanthogranulomas with negative S100 and CD1a stains; PNH fits the bill based on clinicopathologic correlation. (Another key to making a great diagnosis is having brilliant colleagues.)

Rush, Helms, and Mostow, in their thoughtful approach, have developed the acronym CARE (Communicate, Assess for biased reasoning, Reconsider differential diagnoses, Enact a plan) as an efficient, reliable checklist to reduce diagnostic errors, while reminding us to “care” from a humanistic perspective (3).

Shortly after examining the patient described in this commentary, President Trump released a Tweet with a word that kept the world abuzz, trying to decipher its meaning — covfefe. I believe that it is an acronym for reducing diagnostic error:

Cognition (Think about the patient)

Organization (Organize a reasonable differential diagnosis)

Verification (Get appropriate laboratory studies to support or refute your hypothesis)

Find an appropriate therapy

Evaluate (Make sure the patient responds to treatment as expected — if not then…)

Finesse the diagnosis for other considerations and..

Evaluate again as necessary

COVFEFE is an artful approach to seal a diagnostic deal, allowing the clinician to reach precise solutions. This is not just for dermatologists, but for any profession where problems must be solved. It should be employed by attorneys, teachers, architects, engineers, and yes, even the President of the United States!

1. Trimble M, Hamilton H. The thinking doctor: Clinical decision making in contemporary medicine. Clinical Medicine 2016; 4: 343-6.
2. Croskerry P, Nimmo GR. Better clinical decision making and reducing diagnostic error. J R Coll Physicians Edinb 2011; 41: 155-62.
3. Rush JL, et al. The CARE approach to reducing diagnostic errors. Int J Dermatol 2017; 56: 669-73.

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