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Reflections on big lessons from #VMR from #UncleBob - hopefully less that #5goodminutes
@CPSolvers @rabihmgeha @DxRxEdu @Sharminzi @ArsalanMedEd @LindseyShipley8 @SZKamal
CAP
Understanding what the patient means with their words
Naturalistic decision making
Travel history
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CAP
Should we do a schema for "not CAP"? It seems like some of the most fascinating presentations start out as CAP. How can we convince physicians that CAP has a relatively specific illness script against which to compare their problem representation?
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Maybe it is the curmudgeon in me screaming out at this point, but repeatedly I see major diagnostic delays due to a reflex of "abnormal CXR" - CAP. They ignore the history of chronic symptoms rather than acute symptoms. There is often a very incomplete history.
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How often do we mistakenly interpret the patient's language usage to fit our own? We spent (and I am guilty here) too much time on the possibility of platypnea this week without asking key questions to confirm that complaint. Then we never documented orthodeoxia!
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Many overlooked the patient stating that the shoulder pain had no relationship to movement - and that was a big clue.
Another patient had a feeling of impending doom - yet her exam and labs gave no suggestion of doom. And yet we were slow to consider a "non-organic dx"
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Matt on Friday exemplified naturalistic decision making. We discussed this in a JGIM article:
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Schleifer, J. William, Robert M. Centor, Gustavo R. Heudebert, Carlos A. Estrada, and Jason L. Morris. “NSTEMI or not: a 59-year-old man with chest pain and troponin elevation.” Journal of general internal medicine 28, no. 4 (2013): 583-590.
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Dr. Gary Klein, leader in the field of naturalist decision making, proposed recognition-primed decision making. He focuses on the steps to expertise, rather than the causes of errors. This discussion highlights Klein’s greatest contribution – the pre-mortem examination.
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“In this approach, our expert imagines choosing a given dx with its resultant rx. The expert then ... simulates the potential consequences. If the expert still has doubts because the mental simulation raises cautions, he will seek more information before committing to the dx.”
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Matt felt uncomfortable with a headache patient. His problem representation implicitly included some "can't miss diagnoses". Therefore, he referred the pt from urgent care to the ED -> resulting in an efficient, timely evaluation.
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We have had several presentations that involved international travel. The travel has been the clue. But travel within the US is important, especially when fungal diseases are in our differential.
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Finally I reflect on why #VMR is so attractive and useful to me after > 40 years as an attending physician. I am always trying to learn more about medicine. Each session has some AHA moments - and those moments will likely help me make a diagnosis sometime in the future.
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Internal medicine is & has been my vocation and avocation. I love the #VMR community - people with the same love of clinical reasoning. We are all on rising curve of knowledge. This curve likely has no flattening. And we all love learning. We are the best kind of nerds.
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These sessions are the intellectual highlight of each day.
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