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Devils, Angels and Details
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The devil’s in the details, the old saying goes. We all know that this phrase refers to the idea that when you analyze something in detail and go beyond the surface, the true picture of reality will present itself. When it comes to medicine, though, we should change this phrase to the angels are in the details.
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“In the practice of medicine, the angels are in the details”
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Taking care of patients successfully requires a focus on the details. As a teacher of podiatric students and residents, I receive ample exposure to trainees who fail to gather the appropriate and correct information in order to diagnose and treat patients. That is, they fail to look at the details. One of my favorite teaching methods in clinic occurs when students present their patients to me.
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Let’s illustrate. While presenting a patient, student X will make a particular statement about the patient’s history, and I’ll start asking the next logical question. If the student gathered adequate information, and if he is thinking about the patient in a manner similar to me (the correct thinking, obviously!), he should be able to answer my questions. Invariably, though, the student will fail to gather adequate information.
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Student X: “I’m seeing Mr. Z, a 60-year-old diabetic who returns today for follow-up of an ingrown left great toenail.”
Me: “Oh, good. How is Mr. Z doing today?
Student X: “ His toenail is doing well, but he’s noticed a recent increase in tingling and burning sensations in his foot.”
Me: “How long has this been going on?”
Student X: “2 weeks.”
Me: “Is 2 weeks when he first noticed it or when it’s been getting worse? Is it both feet or one foot?”
Student X: “Uh…I didn’t ask that.”
Me: “And how is his blood sugar this morning?”
Student X: “Uh….not sure.”
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For those of you who teach trainees of any level, this is a common situation. Without any other information, the most obvious differentials would be diabetic neuropathy versus lumbosacral radiculopathy. However, the student didn’t ask enough questions to determine the difference. If he would have asked, he might have found out that this problem has actually been ongoing for several months, worsening over the past two weeks, the patient’s blood sugar is 260 mg/dL and both feet are involved. These pieces of information lead us to the unfortunately common presumptive diagnosis of diabetic distal symmetrical polyneuropathy. We’re really making a deal with the devil by treating this patient without knowing the details. It’s all about the follow-up questions.
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“Collecting sufficient details to formulate a good differential diagnosis is all about the follow-up questions. ”
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Similarly, all of the technical aspects of our jobs require an attention to detail for appropriate execution. This is exactly the reason why a detailed knowledge of anatomy is mandatory for the performance of surgery or holding the foot in the correct position is necessary for accurate orthosis casting. The same is true for our own personal growth. In order to improve something you feel weak at, you must ask the detail question. What is it that went wrong? What missing piece of information would allow improvement? Asking that detail question may be difficult at first (that’s the devil part) but will almost invariably end up with a better result than before (the angel part). Any time you want to make yourself better at what you do, consider the devils and angels of the details.
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