We talk a lot about recognizing “sick vs not sick.” We say it’s what you learn intern year, etc.

This phrase has made me increasingly uneasy over time.. I want to explore why:

#MedThread

First, must say: Of course it’s critical to recognize the sick patient. If someone looks unwell, has very abnormal vitals etc, you have to notice it. That gestalt is *specific* enough. Take action.

It’s the “or not sick” that can be problematic...

There are patients who are sick (in this context, have acutely life-threatening illness), but don’t look it.

Lady walking around smiling, bacteremic.

Friend with saddle PE and normal vitals.

Guy who just dissolved an LAD clot, or clotted an aortic bleed - for now..

We often learn this the hard way. So I worry about overemphasizing the “not sick” gestalt because it’s not *sensitive* enough, and has too many false negatives.

But our phrasing and tone often suggest that it’s a reliable judgment. Does he look sick? No? Then he’s not sick.

That brings us to the next point:

What exactly are these criteria for “looking sick?” Hopeful to get a lot of comments here.

But my sense is that they’re much more often alluded to than defined/explicitly taught. And likely different among clinicians.

Finally, there’s a problem with the false dichotomy.. either sick or not sick.

Everything is on a spectrum. I think we can do better than binary assessments.

It may feel like a subtle difference, but I am much more comfortable with the Unstable Watcher Stable system often used in IPASS handoffs these days.

Recap:
- be more explicit/specific when teaching/learning when to conclude that someone is “sick” (please comment!)
- recognize that “not sick” is often an insensitive and hazardous judgment, and consider avoiding the phrase
- acknowledge the spectrum