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In the book 'Give and Take' by Adam Grant, psychologist and professor at Wharton Business School, there is a term called the perspective gap. This refers to our inability to fully appreciate another person's distress when we ourselves are not experiencing a similar kind of distress. The perspective gap explains why physicians often underestimate the severity of the pain that their patients report. In this context, the author of the book gives an account of an incident that occurred in a San Francisco hospital where a respected oncologist wanted a spinal tap done for a patient with advanced metastatic cancer because he wanted to determine if the reason for that patient's deteriorating level of consciousness was meningitis.
The neurologist, who was requested to do the spinal tap, however had his doubts about the need for such a procedure because, not only would the procedure be painful for the patient, he believed it would not result in any significant clinical improvement. The patient and his relatives too did not want the procedure. However, after repeated explanations and much persuasion by the oncologist, the patient and family members agreed to the procedure believing that the oncologist could not be wrong. The neurologist finally did the spinal tap. Soon after that, the patient developed a pounding headache, slipped into a coma and died three days later from the cancer.
The neurologist goes on to say that this incident showed him how the oncologist uncritically accepted the notion that he was doing good. This is the perspective gap that we, as doctors, must always be aware of. The only way to avoid it is to always look at the advice we give to our patients from the point of view of the patients themselves. We should remember the perspective gap when we advice our patients about diabetic diets and also when our prescriptions contain too many medications.

23rd January 2015

A 72 year old man with hypertension was diagnosed to have congestive cardiac failure in June 2014. At that time his serum creatinine was 158umol/L (normal value 60 - 124) and his ultrasound kidneys was reported as showing bilateral renal parenchymal disease. Currently (January 2015) his serum creatinine is 98umol/L and his echocardiogram shows dilatation of both atria and both ventricles. His left ventricular ejection fraction is 45 percent.


  1. Why did ultrasound of the kidneys in June 2014 show "bilateral renal parenchymal disease"?
  2. Why is his left atrium enlarged?
  3. What is the abnormal pathophysiology that led to his right atrium being enlarged?
  4. What do you expect to find if an ultrasound of his kidneys is repeated again now?

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Dr Vela Menon, MD
Clinical Associate Professor of Medicine
International Medical University, Malaysia

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