If We're Changing Guidelines, It's Because We're Learning As We Go Along

Recommendations change as science evolves, not because we make mistakes

- Dr. Edsel Maurice T. Salvana

Medicine is a messy business. As an infectious disease physician, I deal with a multitude of viruses, bacteria, fungi, and other organisms that cause disease. Textbooks describe the classic symptoms of these illnesses. For instance, dengue usually causes fever for about five days, then platelets start to drop two days after the fever goes away. Most people recover. They test positive for dengue NS1, IgM, and eventually IgG most of the time. Occasionally, you’ll get the patient who has only two days of fever, but the platelet count is critically low and all the tests are negative. Still, you are pretty sure it is dengue based on having seen hundreds of these patients and you treat accordingly. This is called a clinical diagnosis.

Clinical diagnosis is an art and a science. You take the disparate parts of a patient’s history, physical examination, and laboratory results and stitch them into a pattern that will tell you what the patient has and how best to treat it.

This is necessary because of two things: The virus never read the textbook and the patient never read the textbook. Medicine and science work on probabilities. For dengue, most patients will have fever, most will have low platelet counts, and most will test positive on the laboratory tests. Some of these, however, will not be present and, in rare cases, may even be contradictory. This is where clinical experience—having seen hundreds of cases and a diversity of patterns— helps doctors decide the best treatment for a patient. Medicine is not a perfect science and therefore what we call the “clinical eye” can mean the difference between getting the correct diagnosis and treatment and missing a crucial diagnosis. It is what makes Filipino doctors, especially those who train at large government hospitals, so exceptional.