The value of open-mindedness as a physician in making accurate clinical diagnoses cost-effective

Open-mindedness is the ability to accept novel ideas and thoughts into one’s repository of thoughts. It entails “thinking outside of the box,” considering unique, uncommon solutions to common and uncommon problems we face daily. An important aspect of open-mindedness, I believe, is to approach difficult scenarios with an open mind, or a tabula rasa—to look at them from a different angle or perspective one would not normally consider. By making decisions under this umbrella of open-mindedness, you must be willing to take a risk, regardless of whether this risk entails a low-reward yield in the outcome, embarrassment, or failure.

To illustrate the value of open-mindedness, let’s do a thought experiment. Think of something you do daily to which you don’t give a second thought. Perhaps this is something you are doing while reading the words on this page. For instance, one activity that many of us engage in throughout the day is walking. When we walk, whether it is inside our homes, at work, or while observing nature, we almost never pay attention to the fact that we are walking. It never occurs to us that we may be walking incorrectly. What I mean by this is that we may have a bad posture when walking or have an unsteady gait. Now I am sure that if we go to a doctor or some other professional, he or she can assess the way we walk and give us advice or consultation as to how we can improve our walking and prevent any health issues down the road. However, to even get to this level of thinking, you must approach the activities you do from the perspective that you have no idea or experience in doing that activity. With walking, you need to take a few steps back and consider: “Am I walking properly? Do I have a steady gait? Do I have any leg or lower back pain?” These questions may seem silly, but they all necessitate being open-minded to even ask oneself these questions. Getting the answers to these questions will allow us to uncover new information or a novel method of doing a particular activity. This unleashes new ways of thinking and will expand one’s repository of knowledge.

In July 1992, I recall meeting a twenty-one-year-old male Saudi patient who came to my clinic complaining of on-and-off dizziness, palpitations, and shortness of breath onset the last two years, stating that these symptoms only occurred upon physical exertion or strenuous activities. His last episode was the evening prior when he was playing soccer and suddenly experienced dizziness, palpitation, and shortness of breath. He did not take any medications at the time. To alleviate his symptoms, he sat down and relaxed for twenty to thirty minutes, at the end of which he returned to baseline. He informed me that he was seen by several physicians from other hospitals, who all informed him that he was suffering from anxiety and told him to not be overly concerned about his symptoms.

While having respect for the other providers’ unanimous diagnosis, I still wanted to go through a physical examination and assessment to approach this situation in a new light and to apply a new pair of eyes to his symptoms. After my physical examination, I did not note any unusual clinical signs or symptoms, such as palpitations or tachycardia, which would have been indicative of some anxiety. The next thing that came to my mind was that he may have had a defect in his cardiac conductive tissues, which generate his heartbeat and are triggered during exercise. I thought that there may have been some accessory pathway that got triggered when he played soccer. I remembered a similar case at Karachi Jinnah Postgraduate Medical Center when I was doing my three-month course in advanced cardiology under Professor Shaukat Syed. Considering this, I asked my nurse to perform an EKG on him in the resting position, which showed normal sinuses and rhythm.

At that point, I could have done what most physicians would have done, which would either have been to closely monitor his symptoms and ask him to come back for a follow-up or refer him for a cardiologist consult. However, at that moment, I started considering the rarer possibilities. Based on my clinical intuition, I had this epiphany that he may have Wolff-Parkinson-White syndrome, which manifests in patients through shortness of breath, rapid pulse, and dizziness. Therefore, under my supervision, while the patient still had EKG leads attached to his chest, I requested him to run for three to five minutes in front of my clinic area. After he came back, he appeared winded and started complaining of palpitations but no chest pain. I immediately had the nurse redo the EKG, which showed a delta wave in the precordial lead V1, which was diagnostic for Wolff-Parkinson-White (WPW) syndrome. A delta wave is a slurred upstroke in the QRS complex and has a short PR interval. This syndrome is usually caused by the presence of an abnormal accessory electrical pathway between the atria and ventricles called the Bundle of Kent. This abnormal pathway electrically signals the heart to contract prematurely, which leads to supraventricular tachycardia. WPW syndrome is a very rare condition that affects between 0.1 and 0.3 percent of the population. My diagnosis was confirmed as WPW syndrome type A because of a positive R wave that was seen in the V1 lead. I called a renowned cardiac electrophysiologist at the King Fahad Hospital in Rayed to present this case. I reported my physical examination, EKG findings, and ultimate diagnosis of WPW syndrome type A to the cardiac electrophysiologist and ultimately referred that patient to him.

Meanwhile, I explained to the patient that the condition had a cure, which entailed the destruction of the abnormal electrical pathway by radiofrequency through catheter ablation. After four weeks, the cardiac electrophysiologist forwarded a report regarding the progress of this procedure with a final diagnosis of WPW syndrome type A. He was really surprised that I was able to conclude that the patient had WPW syndrome. In his five years of practice, he had not seen a single case of WPW syndrome. He appreciated and commended my clinical intuition for obtaining a prompt diagnosis and referral for treatment.

Similarly, in April 1993, I examined a twenty-three-year-old female patient who was eight months pregnant. She was referred to the ob-gyn clinic for evaluation of her shortness of breath and palpitation, which she noticed very recently. I was compelled to believe that the patient may have WPW syndrome based on my clinical intuition and the fact that I had seen a similar case less than a year ago.

Like with the male patient with WPW in July 1992, I had the nurse perform a resting EKG on the patient, which showed normal sinuses and rhythm. However, the follow-up EKG after the patient did some brisk walking showed negative delta waves in V1 consistent with WPW syndrome type B due to excitation of right atrioventricular connections. I chose to wait until her baby was delivered before I referred her to the cardiac electrophysiologist because the catheter ablation could lead to unintended consequences for her unborn child. In July 1993, a couple of months after delivering her baby, the patient had the procedure done by the electrophysiologist and recovered fully.

These two cases demonstrated a degree of open-mindedness in correctly diagnosing the cause of their symptoms. I could have followed standard protocol for these patients and had them referred to cardiology immediately after their resting EKGs were normal. Instead, I chose to take the path less traveled and see if my clinical intuition had any weight to it. In both instances, I took a novel approach at the time to make my assessment, providing patients with the immediate relief that comes from understanding the unknown.


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