Young’s postulate

Having missed the era of describing and, more important, naming classic medical conditions, and most likely lacking the necessary brilliance to forge new scientific frontiers, most of us are destined to end a rewarding career in medicine with a short obituary:

Retired after a busy and satisfying career in medicine … enjoyed bowling and darts … had no discernible genius within or outside of medicine … leaves behind family and friends, and a tree he planted when he was a six-year-old Boy Scout.

Perhaps, on an unconscious level, many of us wish for medical fame, but we are increasingly unlikely to achieve the type of recognition associated with classic terms like Osler’s nodes, Pott’s puffy tumour or Virchow’s triad. In an era of advanced technology, specialized care and gene- or molecule-specific diseases (and disease names), opportunities for eponymous diagnoses are dwindling. Therefore, in an effort to squeeze through the closing window to enduring medical fame, I propose a new medical term, “Young’s postulate”: The last doctor to see the patient is the smartest.

Following a detailed search on Google and Wikipedia, I set out to describe and define the postulate, aiming for a level of fame appropriate to a new, and most certainly enduring, medical eponym.

In a search for any previous use of “Young’s postulate” (8 470 000 results in 0.12 seconds), I discovered that the term was defined in 1970, in an article on physical chemistry, to describe the mixing of liquids, and again in 2008, this time in the context of quantum mechanics. Both prior uses seem not to have achieved substantial recognition, so I feel it safe to pretend they never happened.

Image courtesy of benstevens/iStock/Thinkstock

As defined by Wikipedia, a postulate is a “basic truth”; so far, so good.

Young’s postulate relates to the natural history of a disease process. Wikipedia tells me that the “natural history of disease” is the “uninterrupted progression of a disease in an individual from the moment of exposure to causal agents until recovery or death.” Otherwise stated: If you wait long enough, nearly anyone can make the correct diagnosis.

Allow me to provide some context. Imagine it is early morning, and a sleepy but confident resident is presenting admission rounds regarding “a classic case of [insert condition here].”

“Note how the T2-weighted images on the gadolinium-enhanced contrast MRI show the typical findings of [insert obscure diagnostic term here]. The serum [insert rarely available lab test here] clearly shows a pattern of abnormality associated with the six previously reported cases in [insert obscure journal name here]. The patient is now doing well, having been seen previously, and misdiagnosed, by the referring facility before transfer to our institution.”

Ultimately, the purpose of the postulate is to remind us of the importance of humility, a trait perhaps not sufficiently highlighted in our medical training. Most of us have been, and will continue to be, the first, and therefore not the smartest, doctor to see a patient. We may be competent diagnosticians, but often enough, in the context of a disease presentation and its evolution, we are not seen as the smartest. With care, and a bit of good fortune, we will make the correct diagnosis. If not, we should be able to communicate clearly and humbly to patients and families that as a disease process evolves, a follow-up visit may be required.