Thread by @MohitHarshMD

May the 4th be with you! Tip #4 #TipsForNewDocs #MedTwitter

You’ve probably heard this one time and time again: “read more” or “read up on your patients”

Yet no one tells you HOW they read more and make that information stick!

A 🧵 on the system I developed in residency

https://twitter.com/MohitHarshMD/status/1521604768069820416

I have a terrible memory so I have to brush up constantly

Being told to read more was daunting because the amount to read was overwhelming and I may only retain 10% of the UpToDate article, etc

There are 3 areas I focus on

Dx reasoning
Rx reasoning
Patient Centered EBM

Dx Reasoning:

As many on here describe well, it isn’t the reps. It’s the intentionality to those reps and active reflection on cases that improve your dx skills

If your dx is delayed or incorrect in real life, spend time reflecting on your illness script and cognitive biases

Had a case of gout that we thought was OM on imaging

I talked to our rheum consultant abt gout as a mimicker. I called radiology to learn imaging differences OM vs. tophaceous gout. I read a gout review article

I re-examined our pt’s joints and w/ permission took pics for ref

How to improve dx reasoning is a series of tweetorials in and of itself. I learned immensely from following the works of these ppl below

@CPSolvers @UnremarkableLab @COREIMpodcast @DxRxEdu @DxRxEdu @medrants @Gurpreet2015

Later I’ll do a thread only on improving dx reasoning

Rx Reasoning (Management Reasoning):

This is where “read more” gets thrown around most

I’ve learned via digested, high yield material from @COREIMpodcast @thecurbsiders @iBookCC

Let me share step by step what I do for any clinical question that comes up on inpatient/ICU/clinic

1st you need to ask an answerable clinical ? to narrow reading

Use PICO
P: pt, population, problem
I: intervention, exposure, test
C: comparison of I
O: outcome (pt centered)

Now I have a mgmt dilemma about AC for Afib in ICU. How do I learn the most from this scenario?

I’ll specify my clinical question using PICO:

In critically ill pts w/ high CHADS2VASC score w/ new AF, is there a stroke reduction benefit using heparin gtt for AC?

I’ll do brief lit review for primary articles, RCT, observational data, etc to answer the question

Now that I know some evidence, I’ll do spaced repetition using #FOAMed

The following week I’ll find a relevant podcast from @iBookCC @thecurbsiders @COREIMpodcast to fill in some gaps and learn about the gray zones that trials don’t fully cover

Then comes a mental exercise…

To learn about AF from various avenues, I’ll then re-examine my initial question in a different clinical context:

If I had a ? about AC for AF in ICU, I’ll do mental exercise on how I would manage new AF in outpatient setting and how to decide which AC to pick for pts in clinic

With this mental clinical scenario, I’ll repeat the process of creating a PICO question, using multimedia resources to perform spaced learning to prep for next pt

All this occurs over span of 2-4 weeks using #DigitalMedia to my advantage for asynchronous learning at my own pace

This system helped me to consider various scenarios conditions present by utilizing each individual case as multiple potential mental exercises

The same exercises can help our dx reasoning too. What fits? What doesn’t? What additional data would secure the dx?

A brief note on Pt Centered EBM (more to come later)

As a new doc it’s no longer enough to just know facts, you must be able to use facts/data to make the most patient centered decisions you can w/ pts

This requires knowing and appraising evidence while having Rx humility

I follow the #Zentensivist #Zenternist philosophy on patient care via @PulmCrit @msiuba

Reading this article changed my perspective and practice patterns for the better:

ncbi.nlm.nih.gov/pmc/articles/P…

In summary (thanks for reading this far)

🔥Get intentional reps w/ @CPSolvers etc
🔥Reflect on cases on your own and w/ colleagues
🔥Ask answerable clinical ?s w/ PICO
🔥Look at primary evidence
🔥Spaced learning w/ mental exercises and #DigitalMedia
🔥Focus on Pt centered EBM

@DoctorVig @ETSshow @rabihmgeha @DxRxEdu @ShreyaTrivediMD @aoglasser @YihanYangMD @buckeye_sanjay @medrants @AnandJag1 @SatyaPatelMD @JenniferSpicer4 @rav7ks @ChrisDJacksonMD @MDdreamchaser @RakheeBhayaniMD @abbyWUim @dcoscomd @RosenelliEM @CPSolvers @UnremarkableLab @WashUIMRes