The Internal Alarm System

A Sensible Medicine Medicine Guest Post

I met Mr. A near the end of my first year of internal medicine residency. He presented to the emergency department earlier that day for the acute onset of eye swelling. The CT scan suggested orbital cellulitis. He was started on IV antibiotics, seen by ophthalmology, and admitted to our service. The admission seemed routine. When I spoke to him, however, he surprised me. He had no risk factors for orbital cellulitis. Taking a more detailed history, I learned that he had had a similar episode of eye swelling that resolved months earlier. His previously independent life had taken a sudden turn for the worse over a few short months. He was getting weaker, had skin rashes and fevers that would come and go. On lab tests, his blood counts had been steadily falling for months, and he was developing macrocytosis.

This did not sound like orbital cellulitis.

In the early stages of medical training, we learn diseases in neat and structured paradigms – pathophysiology, diagnosis, and treatment. We memorize common patterns, associations, and risk factors – so-called illness scripts. Yet as we enter clinical practice, we see how patients often do not follow scripts. Histories take unexpected turns, the etiology of symptoms can be multifactorial, and the potential harms and benefits of interventions must be weighed thoughtfully. Over time, we hone our medical knowledge, but increasingly it serves as a foundation for a more sophisticated reasoning system. The mark of the seasoned clinician is not so much the volume of medical facts they remember, but their ability to reason through data – history, exam, labs, imaging – in the context of a knowledge base to make sound judgments. These judgments often don’t lead to immediate answers but prompt us to think more deeply about our patients. We develop an internal alarm system to decide when to reassure and when to worry. I was still a junior doctor, but alarms were going off.

I was worried about Mr. A.

As I learned about more about Mr. A, I convinced myself he had VEXAS syndrome, an autoinflammatory condition seen in older men. As a resident, I was mindful of checking my intuition against common cognitive pitfalls. Had I mistaken the hoofbeats of a horse for a zebra? I had seen VEXAS on the rheumatology consult service at our tertiary care hospital. Could this be recency or availability bias? Yet nothing else quite fit, and my senior resident and attending agreed. Within a few days, genetic testing confirmed VEXAS syndrome. We stopped the antibiotics, started him on prednisone, and saw Mr. A’s eye morph into its normal shape. For the first time in many months, he felt like himself again.

I learned about medicine from diagnosing and treating Mr. A. The diagnosis I made was the result of clinical skill and good luck. I took the time to ask questions and think deeply, but I also benefited from my own recency bias and the foundation of an excellent workup performed by an outpatient primary care physician. How many negative workups had I done in my primary care clinic for vague symptoms? Although my story is not unique, moments like these teach us important lessons we can take into our everyday practice.

We practice medicine in an era where we often have access to advanced diagnostic testing, artificial intelligence, large language models, and subspecialized experts. Although there are cynics, I view these developments with optimism. They expand the toolset at our disposal to fulfill our obligation of reducing our patients’ suffering. But the efficacy of any tool is determined by the judgment of those who wield it. The oncologist Siddhartha Mukherjee wrote in his book, The Laws of Medicine, “a strong intuition is much more powerful than a weak test.” A good history fundamentally guides clinical intuition. Indeed, even the best diagnostic tests are only helpful when the pre-test probability is known. Mr. A’s labs illuminated the path to the correct diagnosis, but it was the history that set me on the right road.

My colleague and friend Yianni Kournoutas wrote that the practice of medicine has us “confront the nuances, surprises, and tragedies of human illness.” I shared my own personal reflections on the central importance of trust, particularly in the face of the tragedies we routinely encounter in clinical medicine. If trust forms the heart of our calling, then it is clinical judgment—our capacity to recognize nuance, confront surprises, and synthesize complexity—that forms the mind. It gives our work intellectual meaning and allows us to fulfill our ultimate obligation to the patients we care for.

Aiman J. Faruqi is a resident in Internal Medicine at The Mayo Clinic.

Photo Credit: Hans Veth