Thread by @medicalaxioms

I’ve reviewed hundreds of M&M type cases in my career.

The most common element between them is anchoring.

Anchoring to
- initial data “her vitals were normal when she came in”
- initial impression “probably a vital syndrome”
- initial judgment “this guy is a drug seeker”
- initial priorities “she isn’t sick and probably doesn’t need to be admitted”

To the best of my ability, I start from scratch when admitting patients to the hospital.

The only fact that I accept is that somebody thought this person was sick enough to need a hospital bed.

At my place they are usually correct.

The one clinical assessment I review 100% of the time is the “nurse triage note.” At the time of discharge, this is associated directly with the final diagnosis about 98% of the time.

It’s amazing how often medicine residents get sent down the wrong track by the pitch from the ER, the differential diagnosis on the xray read or a call from a fellow resident.

“Just another homeless guy in alcohol withdrawal.”

Plenty of admissions come to the medicine service pre-packaged with a home run diagnosis. The ones that don’t are where the internist’s time and systematic approach comes in handy.

You have to stay loose. Fresh. Unencumbered by preconceived notions. Ready to see with your eyes something entirely different than you heard described to you 30 minutes ago.

Now just to blow your mind (and to show you that I’m not bashing the specialties that see patients first) I’ll tell you that I do this with my own self sometimes.

I ignore my own diagnosis from a day or a few hours ago. Forget what I thought and reinvent the wheel.