Educational Strategies to Promote Clinical Diagnostic Reasoning (NEJM 2006;355(21):2217)
· Sit at patients bedside to collect a thorough history.
· Perform an uninterrupted physical examination.
· Generate life-threatening and most likely diagnostic hypotheses.
· Use information databases and expert systems to broaden diagnostic hypotheses.
· Collect data to confirm or exclude life threats first, then most likely diagnoses.
· Avoid diagnostic testing whenever possible by using readily available decision-making algorithms (e.g., Ottawa ankle rules).
· Order only those tests that will affect disposition or that will confirm or exclude diagnostic hypotheses.
· Include decision rules on diagnostic testing order forms.
· Use guidelines and protocols for specific therapeutic decisions to conserve mental energies while on duty.
· Allow 2 to 3 minutes of uninterrupted time to mentally process each patient.
· Mentally process one patient at a time to disposition.
· Avoid decision making when overly stressed or angry. Take 1 to 2 minutes out, regroup, then make the decision.
· Carry a maximum of 4 to 5 undecided category patients. Stopmake some dispositions.
· Use evidence-based medicine techniques to substantiate decisions with evidence, understand the limitations of the evidence, and to answer specific questions, such as usefulness of diagnostic testing, management plans, and disease prognosis.
Life is short, the art long, opportunities fleeting, experience treacherous, judgment is difficult – Hippocrates
Cognitive Forcing Strategies in Clinical Decision Making (Annals EM 41:1, Jan 2003)
Don’t Let an ugly fact ruin a beautiful theory
It’s far easier to keep up than catch up
Empathy as method acting article (JAMA 2005;293(9):1100)
Warnings and Commiserations produce a nocebo effect (Pain 2005;114:303)
The diagnostic approach: the restricted rule-out
Many doctors come to use some variant of the restricted rule-out method, which recognises that we cannot rule out all of the alternative diagnoses for each presenting complaint, but that there is a short list of serious ones that we absolutely must rule out. The method involves constructing a limited list of serious diagnoses to be ruled out, in addition to constructing a conventional list of the most likely differential diagnoses.3 This process utilises features from the history, examination, and investigations. (BMJ April 2009)
Outcome Bias and the Retrospectoscope
outcome biasEM docs changed their perception of the case depending on how the pt didAnn Emerg Med 2011;57:323
System 1 vs. System 2
Acad Med. 2012 Jun;87(6):785-91. doi: 10.1097/ACM.0b013e318253acbd.
The relationship between response time and diagnostic accuracy.
System 2 is not necessarily better in EM