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Index of Suspicion: Puzzles to Solve, Cases to Learn, and People to Heal

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“Clinicians learn medicine best through patient cases. For example, say ‘brain tumor’ and I can immediately think of 4–5 patients I took care of. I know that disease.” – Dr. Lawrence “Larry” Nazarian 2022

While Pediatrics in Review (PIR) published the occasional case report in its early years, a feature dedicated to case reports did not officially appear until 1992, after Associate Editor, Dr. Larry Nazarian, convinced Editor-in-Chief, Dr. Robert Haggerty, that the journal should publish case reports under the rubric “Index of Suspicion,” because sometimes the initial impressions of a patient were misleading, requiring some degree of suspicion for a less familiar, more unusual diagnosis (10.1542/pir.13-3-113). Dr. Nazarian, the founding editor of “IOS,” first wrote of his own patient cases, but soon approached colleagues and readers to provide their own patient experiences. IOS quickly became a very successful feature of PIR, with the editorial office to this day swamped by hundreds of submissions from around the world.

IOS editors Dr. Larry Nazarian, Dr. Deepak Kamat, Dr. Philip (Phil) Fischer, and Dr. Lynn Garfunkel, our current IOS editor, have passionately guided the development of IOS these past 30 years. When talking about IOS, Larry proudly states, “Through IOS, pediatricians shared diagnostic tips and the latest therapies and introduced new educational media such as jpegs and video recordings. For us at the journal there was an unexpected benefit. Our own reviewers enjoyed reviewing the cases and learned something new.”

Lynn writes the following:

So, why do we like the Index of suspicion manuscripts? Do these cases help us learn?

We like puzzles. Puzzles keep us actively engaged; in this method of learning we more actively participate. We are the explorer, the discoverer.  We test our own knowledge, compete with ourselves.

Testing our knowledge on an unknown is...just plain fun, like doing a puzzle.

The cases actively remind us of what we do know....and what we still need to learn.  Prompting this reflection is such an important part of patient cases – in morning report, in case-directed clinic and noon conferences, in IOS manuscripts.

It is not just the piecing together of the story that is crucial but discovering the clues and the absence of clues.  What did the presenter ask or the patient share that will help us reach the correct diagnosis—and what might have been forgotten—what did the patient not mention, what did the doctor not ask about?  Would I ask a different question, or additional questions?  What is the “not important” information that might lead us down the wrong path? What is extraneous? What clues were we given that are not only important but critical?

What do we need to look for on the examination?  Was the examination complete, was it thorough?  How did the physical or laboratory exam help piece the puzzle together?  Is there a laboratory value or imaging study that “opens the lock” or confirms the correct diagnosis?

How do we generate a differential diagnosis? Where does this all fit? Why is one diagnosis more likely to be correct; why is another less likely? 

Learning from case-based methods has been shown to be not only a valuable way to learn, but an asset to improving clinicians’ diagnostic abilities.  Knowing facts (signs, symptoms, diseases, physiology, pathology, and management) is extremely important, but figuring out what the facts are and how to apply them at the bedside is what leads to good patient care.”

This month PIR introduces a new role for IOS, a case series with a common complaint, for which readers can receive continuing medical education credit. This month we share three index of suspicion cases—all involving children with respiratory distress. Each CME question is based on one of the patient cases, but combined, the five CME questions will supplement your knowledge of respiratory distress.

Today IOS further succeeds, illustrating that by sharing cases, we collectively solve puzzles, learn anew, and, in turn, heal lives.

(Written in coordination with Lawrence F. Nazarian, MD, Former Editor-in-Chief and founder of Index of Suspicion, Pediatrics in Review; and Lynn Garfunkel, MD, Associate Editor, Index of Suspicion, Pediatrics in Review)

Figure 1 (top image). The Index of Suspicion heading, first appearing in 1992.

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