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On Being a Doctor |

The Emperor's New Clothes

Faith T. Fitzgerald, MD
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Requests for Single Reprints: Faith T. Fitzgerald, MD, University of California, Davis, Medical Center, Division of General Medicine, 4150 V Street, Suite 2400, Sacramento, CA 95817; e-mail, mailto:bioethics@ucdmc.ucdavis.edu.

From University of California, Davis, Medical Center, Sacramento, CA 95817.

Ann Intern Med. 2012;156(5):396-397. doi:10.7326/0003-4819-156-5-201203060-00017
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In his famous story, “The Emperor's New Clothes,” Danish author Hans Christian Andersen tells of an emperor, vain and pompous, who is scammed by rogues who tell him that that they can weave him royal regalia made of a cloth so exquisite and fine that no one can see it but the most competent and intelligent of persons.




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The "downside" of the EMR
Posted on March 7, 2012
Yehia Y., Mishriki, Physician educator
Lehigh Valley Health Network
Conflict of Interest: None Declared

Dr. Fitzgerald is being too kind when she excuses the errors in the EMR as being due to time constraints. Some of the "errors" I have seen in the EMR border on the inept or incompetent. We have all encountered examples such as the older woman with a prosthetic eye who had fallen and struck her head and whose examination noted her eyes to be "PERRLA". More disturbing is these "errors", at times, border on the dishonest. The "14 system review of systems" documented in patients with a litany of symptoms as being "all negative" or the "cardiovascular exam" listed as "pedal pulses present", etc. This, in my opinion, is to allow for billing at a higher level than should be warranted for what was actually done.

Conflict of Interest:

None declared

A need for diagnostic skepticism
Posted on March 9, 2012
Robert M, Centor, Assoc Dean
UAB, Huntsville Regional Campus
Conflict of Interest: None Declared

Dr. Fitzgerald's beautifully written story really has 2 messages. The first message focuses on the EMR. Too often a diagnosis enters the medical record, and because of the nature of EMR gets perpetuated indefinitely. The EMR does induce some laziness in physicians and especially trainees. Cut-and-paste is quick and efficient and often correct.

We should also focus on the implicit message about diagnostic skepticism. Too often we see physicians and trainees accept proposed diagnoses (from past records, emergency physicians or outpatient physicians) without critically evaluating those diagnoses. Too often we perpetuate diagnostic error by failing to ask the question that Dr. Fitzgerald asked - DOES THIS DIAGNOSIS MAKE SENSE?

Clinician-educators have a responsibility to teach diagnostic skepticism. Internists have a responsibility to practice diagnostic skepticism. We may harm our patients through blind acceptance - EMR or paper chart.

Conflict of Interest:

None declared

The Emperor's New Clothes (incomplete)
Posted on March 26, 2012
Paresh, Jobanputra, Hospital Doctor
Queen Elizabeth Hospital Birmingham
Conflict of Interest: None Declared

Dr Fitzgerald's story is interesting and the points she makes well made. The scenario, one of collusion with respect to a diagnostic label in the absence of convincing evidence is not especially unusual, in my experience. The story however is incomplete. I do not recall Hans Christian Andersen's story well but I cannot help wondering about the impact the ridicule, which must inevitably have followed, must have had on the emperor's subsequent well-being - perhaps that does not matter for a vain and pompous man in a position of power.

Confronting such a patient and removing the suit of clothing that a diagnosis of Ehlers Danlos syndrome provides demands unique skills of a physician. It should therefore come as no surprise that none have dared, thus far. It would perhaps be worth reflecting on how best to do this in order to allow healing to ensue and prevent yet more futile medical and surgical activity. How would the patient described have reacted to changing the suit of clothing to one of Munchausen's syndrome? Or, is that immaterial?

Conflict of Interest:

None declared

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