This issue of Pediatric Annals presents a second set of clinical cases from the Emergency Department of The Children's Hospital of Philadelphia. The first set was presented in the February 2000 issue of Pediatric Annals. They were cases that started one's thinking diagnostically in one direction only to find a "twist" or a roadblock, and then a change in thinking led to the actual diagnosis. The cases presented in this issue represent more of the same.
There is an interesting shift point in medical education. It comes when we move from pattern recognition thinking to pattern exceptional thinking. It is unclear when this shift occurs in the course of formal medical education or whether it is simply individual determination. Clearly, we all move from a point where we think "A + B + C = Diagnosis" to a mechanism of "This could be the diagnosis, but A or B doesn't quite fit in; therefore, an alternative diagnosis must be sought." This shift in thought process is one that distinguishes an individual's diagnostic ability.
Do you accept the common diagnosis or do you seek the exceptional or unusual? In always seeking the exceptional or unusual, one is often disappointed because the common is more prevalent. However, on other occasions, that special diagnosis is made and a child is saved from pain, excessive diagnostic studies, or worsening morbidity. Finding the rare diagnosis is a true thrill.
My colleagues in the Emergency Department at The Children's Hospital of Philadelphia are always on the lookout for the unusual, the rare, the variation, or the twist. This is important because we are constantly seeing children who have been referred because they are not "following the rules," are not getting better, do not have an apparent diagnosis, or have parents who are seeking answers. Challenging diagnoses are the rule rather than the norm.
I respect my colleagues immensely not only for thinking critically and challenging constantly, but also for doing both in a way that does not negate their warmth and sensitive approach to the child and their support and guidance to the parents. I hope you enjoy this series of cases as I enjoy working with the dedicated physicians who prepared them for you. Our collective thanks to Dr. Kathy Shaw, the Director of the Emergency Department, for her strong leadership.