Discover and read the best of Twitter Threads about #diagnosticreasoning
Most recents (5)
Expert clinicians utilize targeted debiasing strategies almost instinctively
@rabihmgeha at #SGIM23 employing “What can’t I explain?” for a pt w “CHF exacerbation” hypoxic to 70% on RA, improved to 92% on 3L
Photo from my recent Cognitive M&M courtesy of @UABMedPeds @uabimres
@rabihmgeha at #SGIM23 employing “What can’t I explain?” for a pt w “CHF exacerbation” hypoxic to 70% on RA, improved to 92% on 3L
Photo from my recent Cognitive M&M courtesy of @UABMedPeds @uabimres
He emphasized: the crux of the case probably lies in this one point.
That you went from “may need to intubate” to “looks great” with only 3Lnc?
Doesn’t add up…
Consider an alternative etiology for his hypoxemia — notably, w such profound response to minimal O2, hypercarbia
That you went from “may need to intubate” to “looks great” with only 3Lnc?
Doesn’t add up…
Consider an alternative etiology for his hypoxemia — notably, w such profound response to minimal O2, hypercarbia
Spot on, as always!
Pt admitted for diuresis. Became progressively somnolent - gas showed marked respiratory acidosis, CTH w cerebral edema — all d/t hypercarbia 2/2 OSA
So. Anytime I utilize “What can’t I explain?” in a diagnostic timeout, I create a new brief script.
Pt admitted for diuresis. Became progressively somnolent - gas showed marked respiratory acidosis, CTH w cerebral edema — all d/t hypercarbia 2/2 OSA
So. Anytime I utilize “What can’t I explain?” in a diagnostic timeout, I create a new brief script.
Knowing when to test (vs) when not to test is the hallmark of a seasoned clinician.
But how to you teach this?
Follow this 🧵 to help your trainees navigate uncertainty.
#MedTwitter #FOAM #diagnosticreasoning
@medrants @AdamRodmanMD @EmilyAbdoler @DxRxEdu @rabihmgeha
1/17
But how to you teach this?
Follow this 🧵 to help your trainees navigate uncertainty.
#MedTwitter #FOAM #diagnosticreasoning
@medrants @AdamRodmanMD @EmilyAbdoler @DxRxEdu @rabihmgeha
1/17
The art & science of #diagnosticreasoning is still in its infancy but we now at least have a shared language to navigate the unknown and have meaningful conversations.
2/17
2/17
That said, much nuance and variability exist with how clinicians approach and explain the diagnostic process to trainees.
At some point, the conversation usually ends with something like...
“… b/c it won’t change management”
3/17
At some point, the conversation usually ends with something like...
“… b/c it won’t change management”
3/17
1) The clinical exam receives a lot of flak everyday but we forget one very simple thing.
Many investigations like the USG or echo are highly operator dependent.
Many investigations like the USG or echo are highly operator dependent.
2) Secondly, the cornerstone of all investigations is basically clinical correlation.
Imaging or lab findings by themselves are not to be taken too seriously --> without a clear clinical issue.
This is what we have been taught and it works!
Imaging or lab findings by themselves are not to be taken too seriously --> without a clear clinical issue.
This is what we have been taught and it works!
3) This is important for all residents.
Don't order investigations blindly without understanding the reasoning and defining a clinical question that needs to be answered.
You need concordance btw all three --> hx, findings and labs!
Don't order investigations blindly without understanding the reasoning and defining a clinical question that needs to be answered.
You need concordance btw all three --> hx, findings and labs!
Formulating and appraising your PR (problem representation) is critical to the diagnostic process, and intrinsically welcomes cognitive bias
Work this case with me #MedTwitter
ED calls for admission: “40yo M w pneumonia”
*fist pump* sweet, easy admission
1/
Work this case with me #MedTwitter
ED calls for admission: “40yo M w pneumonia”
*fist pump* sweet, easy admission
1/
“Fever, cough, dyspnea x2d. WBC 20, triggered sepsis. Got cx, fluids, abx. CXR RLL infiltrate. Needs admission for sepsis 2/2 CAP”
With that PR, slam dunk pneumonia.
100% match for my CAP illness script, don’t even need my dyspnea schema (courtesy of @DxRxEdu @CPSolvers)
With that PR, slam dunk pneumonia.
100% match for my CAP illness script, don’t even need my dyspnea schema (courtesy of @DxRxEdu @CPSolvers)
#CognitiveBias of premature closure
+
cognitive load of retaking a full hx on such an “easy admission” 12hrs into call
=
Cutting corners in the name of “efficiency”
So you confirm a preconceived HPI
Fever✅
Cough✅
Leukocytosis✅
CXR infiltrate✅
Community acquired PNA✅
2/
+
cognitive load of retaking a full hx on such an “easy admission” 12hrs into call
=
Cutting corners in the name of “efficiency”
So you confirm a preconceived HPI
Fever✅
Cough✅
Leukocytosis✅
CXR infiltrate✅
Community acquired PNA✅
2/
#ACPOR19 Dr. Jacque Levene presenting her oral clinical vignette!
#acpor19 rocking an enabling hypothesis-driven differential diagnosis! #clinicalreasoning #diagnosticreasoning
#ACPOR19 it’s all about the problem statements and the Illness scripts
