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September 9, 2013

Diagnostic Decision-Making, Burdens of Proof, and a $6000 per Hour Memory Lapse

Author Affiliations
  • 1Department of Neurology, Massachusetts General Hospital, Boston
JAMA Intern Med. 2013;173(16):1493-1494. doi:10.1001/jamainternmed.2013.8409

The goal of clinical diagnostic decision-making is to establish a correct diagnosis with maximal certainty. To this end, tests are often used to supplement the clinical examination and to provide greater accuracy and confirmation. However, given current concerns over health care costs, the sufficiency of each test in each patient’s clinical situation deserves consideration.

For example: In July 2009, my 65-year-old, healthy sister traveled to a friend’s funeral. Following a prolonged period of crying and sobbing, she suddenly experienced memory difficulties and disorientation, repeatedly asking where she was, why she was there, who were the people around her. She was taken by ambulance to a local hospital. While in the emergency department my niece described the symptoms to me via telephone. I diagnosed a well-defined neurological syndrome, transient global amnesia (TGA), and said that my sister would return to normal mentation within hours. I spoke to the treating emergency physician, who independently made this diagnosis, and we mused about its alarming presentation and benign prognosis; virtually all cases resolve completely with recurrences exceptional. My sister’s memory deficits resolved after 6 to 7 hours in the emergency department. Nevertheless she was admitted overnight and underwent a workup with results that were entirely normal.

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