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 Medicine University of California, San Francisco SFVA Medical Center 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 1
4/14/2016 “The role of a GP is to tolerate Consider an experience with a uncertainty, explore probability & missed or delayed diagnosis. marginalize danger; while the role of the hospital specialist is to – what factors were at play? reduce uncertainty, explore possibility & marginalize error. ” Marinker M. General practice and the social market . Social Market Foundation, 1989 A previously 1. UTI A previously 1. UTI healthy 24yo healthy 24yo 2. UTI 2. UTI woman presents woman presents 3. UTI 3. UTI with acute dysuria, with acute dysuria, frequency, urgency frequency, urgency & a positive UA. and a positive UA. 2
4/14/2016 A 67yo man with 1. ? A 67yo man with 1. ? cirrhosis 2/2 HCV, cirrhosis 2/2 HCV 2. ? 2. ? & ESRD on HD and ESRD on HD 3. ? 3. ? presents with presents with chronic fevers, chronic fevers, unintentional unintentional weight loss, & weight loss, and bloody diarrhea. bloody diarrhea. A Case System System System System 1 1 2 2 3
4/14/2016 52yo woman seen in clinic with Course suprapubic abdominal pain • Trimethoprim/sulfa prescribed • PMH: HTN, HLD, GERD, Constipation • After course: on-going suprapubic • Meds: Hydrochlorothiazide, Simvastatin pain; now fevers; no dysuria • Exam: Mild suprapubic TTP • Prescribed cipro • UA: 52 WBC, + LE • Persistent pain, abd U/S ordered Course • ED: tachycardic, peritoneal signs The One-Liner: • CT: perf of sigmoid colon Problem Representation • Emergent OR: resection & colostomy • Dx: Sigmoid Perforation 2/2 Stercoral ulceration 4
4/14/2016 52yo woman with DM, COPD 52yo immunosuppressed on prednisone, hypertension, woman with acute on chronic depression, chronic back back pain, unrelieved by rest & pain, & GERD here for follow- accompanied by severe point up, requesting refill of pain tenderness @ L2-3. meds. Ingredients Illness Scripts • Who is this patient? –Epidemiology/Risk factors • What is the clinical syndrome? –Signs/Symptoms • What is the time course? 5
4/14/2016 Cognitive Error Community Acquired Pneumonia Risk Factors Age, chronic illness (COPD, Heart dz), immunosuppression, • Hundreds described… smokers Signs/Sx Productive cough, SOB/DOE, Fevers, Pleuritic CP, Elderly present atypically* Time course Acute Pathophys Strep Pneumo, Mycoplasma, Viruses, H flu, Chlamydia, Legionella Dx PA/Lat CXR, may miss if patient dry* Outpt: Doxy or Azithro; recent abx quinolone; CURB-65 for triage Rx • 56yo diabetic man in clinic with a red, hot, • 56yo diabetic man in clinic with a red, hot, swollen LE swollen LE • Diagnosed with cellulitis, prescribed • Diagnosed with cellulitis, prescribed amoxicillin amoxicillin • Returns after completing course with • Returns after completing course with increased pain, reduced exercise tolerance increased pain, reduced exercise tolerance • Exercise tolerance thought to relate to painful • Exercise tolerance thought to relate to painful cellulitis, switched to clindamycin for MRSA cellulitis, switched to clindamycin for MRSA coverage coverage • Ultimately, seen in ED, found to have an O2 • Ultimately, seen in ED, found to have an O2 sat of 88%, diagnosed with a PE sat of 88%, diagnosed with a PE 6
4/14/2016 • 34yo man with headaches • 34yo man with headaches • No clear alarm symptoms • No clear alarm symptoms • Diagnosed with migraine • Diagnosed with migraine • 6 months later, he has head imaging • 6 months later, he has head imaging & is found to have Glioblastoma & is found to have Glioblastoma Multiforme Multiforme Building Expertise Vertically Risk Signs/Sx Time Pathophys course CAP Acute Interstitial Pneumonia Sarcoidosis Ericsson A. Acad Med 2004 7
4/14/2016 Follow-Up Enables Deliberate Practice Follow-Up Enables Deliberate Practice • Identify & fill gaps in illness scripts • Review PR –+UA with adjacent inflammation –Stated? (diverticulitis, other inflammatory GI –Did it evolve appropriately? processes) –Did it contain key info? –Did it over-emphasize the wrong info? –Stercoral ulceration in chronic constipation Follow-Up Enables Deliberate Practice • Did cognitive bias impact decision- making? Strategies for –Diagnostic momentum? Diagnostic Follow-up? 8
4/14/2016 Strategies Take Home Points • System I/II, Problem Representation & • Flag provisional dx for diagnostic Illness Scripts offer opportunities for verification deliberate practice • Track via EMR (pt lists) – Pause to state a one-liner • Track on secure server (spreadsheet) – Pause to expand your illness scripts • Mini clinic M&M conferences – Flag provisional dx to enable follow-up –Normalize & share 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 opportunities 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. 2 nd 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 9
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