You have to forgive me, it’s not me, it’s my mind, it’s very slow, and I have to pin everything down.
-Lieutenant Columbo

With his rumpled raincoat, ever-present cigar, bumbling demeanor and Sherlock Holmesian powers of deduction, disarmingly polite homicide detective Lieutenant Columbo took on some of the most cunning murderers in Los Angeles  most of whom made one fatal, irrevocable mistake: underestimating his investigative genius.

One of my favorite TV shows, and probably my favorite mystery series.  Peter Falk played Columbo, and every episode was a joy.  As the quotes indicate, this show had a recurrent them, Columbo wanted to explain each detail.

In medicine, many great diagnosticians excel when confronted with a diagnosis that does not fit the presentation.  Like Columbo, they match the problem representation (succinct clinical presentation) against the presumed illness script.  They key to these great diagnosticians comes from their outstanding knowledge of illness scripts.  When something does not fit, they wonder whether they need to consider a different illness script.

In a typical Columbo episode, a detail grabs Columbo and will not let go.  He cannot rest until he can explain that detail.

I believe that great diagnosticians use the same technique.  A lab value is not easily explained; a historical feature does not fit the presumed diagnosis; the patient either looks too sick, or not sick enough.

If we want our students and residents to become great diagnosticians, we must teach them about the details that do not fit.  We must consider a different diagnosis than community acquired pneumonia when the symptoms have persisted for 3 weeks despite standard treatment.

So unleash your inner Columbo.  Obsess over the details.  Make the correct diagnosis as correct diagnoses make treatment success more likely.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.