, 22 tweets, 11 min read Read on Twitter
A Thursday #MedThread #Tweetorial. Consider this an “ode to uncertainty and curiosity” meshed with my clinical practice passion #periopmedicine inspired by many recent #medtwitter, podcast, & IRL role models and conversations about… 1/X
* Stepping into the tension of clinical uncertainty
* Self-reflecting & identifying when we’re on
the edge of uncertainty
* Being able to say “I don’t know”
* Seeing what’s on the margin of our knowledge
* What it means to be “curious”
@ETSshow @CPSolvers @DxRxEdu
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Also drawing from @Gurpreet2015 OHSU #GrandRounds week—as adult learners & clinicians, we must create micro-learning challenges for ourselves:
* What’s the next step
* What else
* What if
* What’s the next logical question to ask the patient, myself, a colleague?
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How on earth does this apply to #periopmedicine? Isn’t preop all algorithmic decisions, especially ones that just lead us to order tests anyway…I’m looking at you, “dreaded step 6” of the 2014 ACC/AHA algorithm
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NOPE!
1 #periopmedicine is not just testing. It’s a patient-centered H&P. You need to TALK TO A PATIENT, examine them, & reason through pre-op challenges. This is clearly supported by the language & outline of the 2007 ACC/AHA guidelines. It literally starts with “history”
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Two, the algorithms are not all or nothing, clearly test/don’t test. There’s the annoying huge (at times) grey zone, the dreaded “if it will change management”. Again, eyes on you “dreaded step 6”…
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Three, it’s about far more than a black/white check-boxed
assessment of if a patient preparing for surgery at XYZ condition or not. What’s
my mantra?
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And why is that? Knowing certain specifics facilitates patient-centered care, lowers complications, and enhances risk/benefit discussions
(btw, correction from “power” to “empowering” made by patient years ago)
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Just some quick example here, & then I’m moving on to the meat of this #MedThread
* Degree of LV dysfunction and presence/absence symptoms stratifies risk (recent jamanetwork.com/journals/jama/…)
* Asymptomatic severe valve disease isn’t a barrier to surgery (2014 ACC/AHA)
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So what's my point? Last week, I brought up the questions/themes of "curiosity” & “uncertainty” at our Preop Clinic QI meeting, as I had been hearing from team the challenges of feeling comfortable with when to rely on patient subjection v necessitating actual
records...
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...of fighting chart lore in the EHR, of trying to reconcile
vague/inaccurate/overturned information…with these common themes...
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We turned it into a group discussion of:
* How do we recognize and articulate that uncertainty?
* How do we stay curious?
* What do I ask next?
* Where do I look next?
* Do I need to order an ECHO/stress test to settle this??
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We discussed the VALUE of using our history & exam skills, along with our ability to communicate our clinical reasoning process (sorry but through charting…) in a transparent fashion that then EMPOWERS the surgeons and anesthesiologists caring for our patients next
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Here’s an example of chart lore, working backwards from how a patient might have presented to pre-op clinic with certain information in the chart:

⬅️ “History of coronary disease”

⬅️“history of MI”

⬅️“chest pain” with elevated troponin

What was this originally??
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It was actually from an emergency room visit for MVA with steering wheel trauma and a troponin leak from cardiac contusion in a previously healthy patient

“CAD” got deleted from the EHR and the patient did
NOT get a preop stress test
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I SO think of Dr. Faith Fitzgerald’s piece “Curiosity” here:
annals.org/aim/fullarticl…
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Also from “Curiosity”:
“Technology is wonderful and seductive, but when seen as more real than the person to whom it is applied, it may also suppress curiosity.”

What examples did we share from within preop clinic?
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Being curious does NOT mean you will never end up ordering pre-op testing—staying curious lets you question the need for pre-op testing, as I discussed in this prior #tweetorial on aortic stenosis, inspired by multiple such
conversations w patients:

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We also need to cycle back to even the “slam dunk” cases. How did the story end?
What DID that pre-op ECHO show? That stress test? That cath?
This is a chance to reflect when you get the result v just typing “ok to proceed with surgery”

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As a tangent, I’ve been so excited to see the clinical reasoning cases & discussion forums lately, multiple core points including the fact that challenging cases don’t have to end up being zebras. Even “bread & butter” diagnoses can be challenging to diagnosis.
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I would love to see more periop case (both pre- & post-op differentials) out there
Gratuitous plug to @OHSUIMRes R2 Dr. O’Donnell who
published one such periop piece in #SGIMForum in 12/2018, and
Dr. Katie Ferguson will have a piece out in June!
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sgim.org/File%20Library…
So final lessons, even & esp in #periopmedicine:
* Stay curious
* Acknowledge uncertainty
* Talk to and examine your patients
* Keep learning and growing from the care you’ve provided and decisions you’ve made for prior patients
Thank you for reading & reasoning!
FIN 22/22
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