Procrustes

I am guilty, guilty as sin.

I think I commit this particular crime on a fairly regular basis, but I am trying to get better.

No, not speeding, not gluttony (although some might disagree), certainly not anything as serious as murder, but still, this crime has the potential to cause harm, and long-lasting harm at that.

So what crime is it, some sort of fraud?  I guess so… it is:

The Crime of Procrustes.

Procrustes was a robber (and wayward son of Posiedon) who lived in Attica and had a particularly nasty way of ‘helping’ his victims.  He would invite travellers on the road to Athens (or Eleusis) to come in and stay the night in his fort, promising them a comfy bed which had amazin properties – namely that it was a perfect fit for everyone.

The slight issue was how this bed managed such a seemingly impossible task.

Well, if you happened to be too long for Procrustes bed, you would be cut down to size, and if you happened to be a bit short, then there were handy winches at each end of the bed to ensure that you would fit just right (after a bit of stretching.) To catch out those lucky ones who fitted the bed without adjustment – he had two beds!

So, a nasty chap – and not an invitation you would want to accept – and thankfully, Theseus put an end to this practice by getting Procrustes to ‘fit’ his own bed when he stayed the night on his way to Athens.

So – what manner of torture chamber do you imagine I keep at home? Thankfully not – only a toddler bed which feels like torture if you are ever unfortunate enough to have to kip on it.

And what does this have to do with me?

The crime I am guilty of is of fitting information to the case I wish to make, rather than using it without prejudice to form an accurate picture of what is going on.

This is an easy trap to fall into, and causes real problems. The trap is often set unwittingly by those who are taking the initial details from the patient – be that the GP, the ambulance crew, or the A+E staff.  The initial phase of a patients admission is often a confused/confusing time, and the diagnosis is often attempted on incomplete information, or without the benefit of the increasing volume of data we generate about patients from the time they arrive in the hospital.

There is a desire amongst the medical profession to be right (it is, after all what we are drilled to do for 5 years or more at medical school) and there is a particular satisfaction in being able to tell a patient what is wrong with them.

Once enough information is gathered to have a reasonably firm diagnosis, it is usually written at the top of a differential – and becomes the working diagnosis.

The difficulty is that this suggestion, when a new pair of eyes comes to pick up the thread of the story, influences their thinking and sets them in the ways of Procrustes.  Further information as it is gained seems to reinforce the original diagnosis, and thereafter it is incredibly difficult to challenge it.

Now, there are a few caveats – the initial diagnosis has to hold some weight for this process to play out.  The medical tribes and hierarchies which exist mean that if the working diagnosis was made by someone that you consider to be less good than you, you will have little difficulty overturning it.  However, if someone of stature makes the initial diagnosis and plan – then it is increasingly difficult to turn the thinking around – and it somehow seems easier to fit the information to what we want to believe.

The key to avoiding this is being aware of the influences on you when you approach a case – especially if you are junior.

The data will be what it is, no matter what spin one tries to put on it. If things are not adding up, or there are inconsistencies in what is going on – go back to the beginning, and re-examine.  It has never ceased to amaze me how many diagnoses are challenged by the juniors on ward cover at night – and I am certain that it is because there is less distraction, more time to focus, and less fear of looking stupid if one questions the status quo.

So please, next time you are faced by a slightly ropey diagnosis, or are trying to explain away anomalies in what you are seeing – think again and try to avoid being guilty.

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