Disclosures I have no actual or potential conflicts of interest to - - PDF document

▶
disclosures
SMART_READER_LITE
LIVE PREVIEW

Disclosures I have no actual or potential conflicts of interest to - - PDF document

Oct 25, 2022 25 likes •119 views

4/14/2016 Disclosures I have no actual or potential conflicts of interest to report in relation to this Sharpening Our Procedure: presentation. Fostering Expertise in Clinical Reasoning Denise M. Connor, MD Assistant Clinical Professor of

slide-1
SLIDE 1

4/14/2016 1

Sharpening Our Procedure:

Fostering Expertise in Clinical Reasoning

Denise M. Connor, MD

Assistant Clinical Professor of Medicine University of California, San Francisco SFVA Medical Center

Disclosures

  • I have no actual or potential conflicts
  • f interest to report in relation to this

presentation.

Objectives

  • Describe System I/II, Problem

Representation, & Illness Scripts

  • Appreciate the role of cognitive error

in missed diagnoses

  • Recognize opportunities to hone dx

skills amidst busy clinical practice

slide-2
SLIDE 2

4/14/2016 2

“The role of a GP is to tolerate uncertainty, explore probability & marginalize danger; while the role

  • f the hospital specialist is to

reduce uncertainty, explore possibility & marginalize error.”

Marinker M. General practice and the social

  • market. Social Market Foundation, 1989

Consider an experience with a missed or delayed diagnosis.

– what factors were at play?

A previously healthy 24yo woman presents with acute dysuria, frequency, urgency & a positive UA.

  • 1. UTI
  • 2. UTI
  • 3. UTI
  • 1. UTI
  • 2. UTI
  • 3. UTI

A previously healthy 24yo woman presents with acute dysuria, frequency, urgency and a positive UA.

slide-3
SLIDE 3

4/14/2016 3 A 67yo man with cirrhosis 2/2 HCV, & ESRD on HD presents with chronic fevers, unintentional weight loss, & bloody diarrhea.

  • 1. ?
  • 2. ?
  • 3. ?

A 67yo man with cirrhosis 2/2 HCV and ESRD on HD presents with chronic fevers, unintentional weight loss, and bloody diarrhea.

  • 1. ?
  • 2. ?
  • 3. ?

System 1 System 1 System 2 System 2

A Case

slide-4
SLIDE 4

4/14/2016 4

52yo woman seen in clinic with suprapubic abdominal pain

  • PMH: HTN, HLD, GERD, Constipation
  • Meds: Hydrochlorothiazide, Simvastatin
  • Exam: Mild suprapubic TTP
  • UA: 52 WBC, + LE

Course

  • Trimethoprim/sulfa prescribed
  • After course: on-going suprapubic

pain; now fevers; no dysuria

  • Prescribed cipro
  • Persistent pain, abd U/S ordered

Course

  • ED: tachycardic, peritoneal signs
  • CT: perf of sigmoid colon
  • Emergent OR: resection & colostomy
  • Dx: Sigmoid Perforation 2/2 Stercoral

ulceration

The One-Liner: Problem Representation

slide-5
SLIDE 5

4/14/2016 5 52yo woman with DM, COPD

  • n prednisone, hypertension,

depression, chronic back pain, & GERD here for follow- up, requesting refill of pain meds. 52yo immunosuppressed woman with acute on chronic back pain, unrelieved by rest & accompanied by severe point tenderness @ L2-3.

Ingredients

  • Who is this patient?

–Epidemiology/Risk factors

  • What is the clinical syndrome?

–Signs/Symptoms

  • What is the time course?

Illness Scripts

slide-6
SLIDE 6

4/14/2016 6

Community Acquired Pneumonia

Risk Factors Signs/Sx Time course Pathophys Dx Rx Age, chronic illness (COPD, Heart dz), immunosuppression, smokers Productive cough, SOB/DOE, Fevers, Pleuritic CP, Elderly present atypically* Acute Strep Pneumo, Mycoplasma, Viruses, H flu, Chlamydia, Legionella PA/Lat CXR, may miss if patient dry* Outpt: Doxy or Azithro; recent abx  quinolone; CURB-65 for triage

Cognitive Error

  • Hundreds described…
  • 56yo diabetic man in clinic with a red, hot,

swollen LE

  • Diagnosed with cellulitis, prescribed

amoxicillin

  • Returns after completing course with

increased pain, reduced exercise tolerance

  • Exercise tolerance thought to relate to painful

cellulitis, switched to clindamycin for MRSA coverage

  • Ultimately, seen in ED, found to have an O2

sat of 88%, diagnosed with a PE

  • 56yo diabetic man in clinic with a red, hot,

swollen LE

  • Diagnosed with cellulitis, prescribed

amoxicillin

  • Returns after completing course with

increased pain, reduced exercise tolerance

  • Exercise tolerance thought to relate to painful

cellulitis, switched to clindamycin for MRSA coverage

  • Ultimately, seen in ED, found to have an O2

sat of 88%, diagnosed with a PE

slide-7
SLIDE 7

4/14/2016 7

  • 34yo man with headaches
  • No clear alarm symptoms
  • Diagnosed with migraine
  • 6 months later, he has head imaging

& is found to have Glioblastoma Multiforme

  • 34yo man with headaches
  • No clear alarm symptoms
  • Diagnosed with migraine
  • 6 months later, he has head imaging

& is found to have Glioblastoma Multiforme

Ericsson A. Acad Med 2004

Building Expertise Vertically

Risk Signs/Sx Time course Pathophys

CAP Acute Interstitial Pneumonia Sarcoidosis

slide-8
SLIDE 8

4/14/2016 8

Follow-Up Enables Deliberate Practice

  • Identify & fill gaps in illness scripts

–+UA with adjacent inflammation (diverticulitis, other inflammatory GI processes) –Stercoral ulceration in chronic constipation

Follow-Up Enables Deliberate Practice

  • Review PR

–Stated? –Did it evolve appropriately? –Did it contain key info? –Did it over-emphasize the wrong info?

Follow-Up Enables Deliberate Practice

  • Did cognitive bias impact decision-

making?

–Diagnostic momentum?

Strategies for Diagnostic Follow-up?

slide-9
SLIDE 9

4/14/2016 9

Strategies

  • Flag provisional dx for diagnostic

verification

  • Track via EMR (pt lists)
  • Track on secure server (spreadsheet)
  • Mini clinic M&M conferences

–Normalize & share

Take Home Points

  • System I/II, Problem Representation &

Illness Scripts offer opportunities for deliberate practice

– Pause to state a one-liner – Pause to expand your illness scripts – Flag provisional dx to enable follow-up

This work by Denise M. Connor is licensed under a Creative Commons Attribution‐NonCommercial 4.0 International License

References & Additional Reading

  • Bowen JL. Educational strategies to promote clinical diagnostic
  • reasoning. N Engl J Med. 2006 Nov 23;355(21):2217-25.
  • Botros J, Rencic J, Centor RM, Henderson MC. Anchors away. J

Gen Intern Med. 2014 Oct;29(10):1414-8.

  • Ericsson KA. Deliberate practice and the acquisition and

maintenance of expert performance in medicine and related

  • domains. Acad Med. 2004 Oct;79(10 Suppl):S70-81.
  • Goyder CR, Jones CH, Heneghan CJ, Thompson MJ. Missed
  • pportunities for diagnosis: lessons learned from diagnostic errors in

primary care. Br J Gen Pract. 2015 Dec;65(641):e838-44.

  • Kassirer JP, Wong JB, Kopelman RI. Learning clinical reasoning. 2nd
  • ed. Baltimore: Lippincott Williams & Wilkins; 2010.
  • National Academies of Sciences, Engineering, and Medicine. 2015.

Improving diagnosis in health care. Washington, DC: The National Academies Press.

  • http://www.improvediagnosis.org/?ClinicalOverview