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Articles: Reham El Gammal, Christina Fernandez, Shahab Abdessalam, Lindsay Chase, Rebecca Scherr, and Jeffrey M. Karp Index of Suspicion Pediatrics in Review 2008; 29: 437-444 [Full text] [PDF]

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Rare birds, zebras and fasinomas

David R Kosten   (24 June 2009)

Rare birds, zebras and fasinomas 24 June 2009
David R Kosten, Pediatrician Clarian Health Partners Send letter to journal: Re: Rare birds, zebras and fasinomas dkosten{at}clarian.org David R Kosten	I am writing you today to tell you that the Index of Suspicion has gotten too hard. I am practicing primary care pediatrician, and have been for over two decades. I depend on Pediatrics in Review as one of my primary sources of CME and I am grateful to the authors and editors for the fine work that they do. Recently, I have noticed that many of the answers of the case studies describe diseases that happen at a frequency of 1 in 100,000 or even more rarely. Or the answer describes a combination of diseases about which the authors will state that this is the first, or fifth, or tenth time that this has ever been described. Realistically, for the average pediatrician to encounter any of these diseases they would have to practice hundreds, if not thousands of years. I have been reading PIR long enough to know that the editors stock response is that it is not the answer that is important, but the process of the reader developing the differential diagnosis. My response is that for me to engage with the Index of Suspicion I need to feel that the child with the described condition is behind the next exam room door. When I lose that feeling doing the Index of Suspicion just becomes drudgery. Or, as we all no from childhood, if you don't let me win every once in a while then I no longer want to play the game. My proposal is that the editors discourage submission of Index of Suspicion cases if the frequency of the illness is less than 1:50,000 children. As a comparison PKU disease is 1:15,000. Also, my proposal would rule out any submission in which the phrase “…this case is only Xth reported instance…” where X is less than 1000, appears. I have noticed that the authors of many of these writers are residents and staff from academic medical centers. Perhaps the editors of Index of Suspicion might guide the authors away from submitting their trophy fasinoma towards cases that illustrate commonly missed diagnostic opportunities on the part of primary care doctors. Conflict of Interest: None declared