Module 2: Clinical Problem Solving Flashcards
conditions that promote diagnostic errors
- uncertainty everywhere
- novel situations
- high decisions density
- handoff problems
- time constraints
- workload stress
- low signal to noise ratio
- high cognitive load
- shift work factors
- constant interruptions
- physical & emotional stress
cognitive error categories
- technical errors
- faulty knowledge
- faulty data gathering
- faulty information processing
- faulty verification
- unchecked biases
anchoring bias?
- focus on 1st piece of info aka premature closure
- is the most common diagnostic error
- fail to continue considering reasonable alternatives after initial (working) dx is reached
availability bias?
- reliance on things that might immediately come to mind
- tendency to judge things as being more likely if they readily come to mind
confirmation bias?
- looking only for evidence that confirms/supports diagnosis
- don’t look for disconfirming evidence to refute initial diagnosis
- ignore evidence that contradicts diagnosis
unpacking principle
- Keep it simple silly
- failure to elicit all relevant information before a differential diagnosis is established
- result in significant possibilities being missed
overconfidence?
- tendency to believe we know more than we do
- tend to act on incomplete info, intuition or hunch
- too much faith placed on initial impression, rather than carefully collected data
diagnostic momentum?
- chart lore or copy forward
- once a diagnostic label is attached to a condition it’s hard to remove it
- tendency to not to want to override it
visceral ‘attribution bias’
- stereotypes
- negative feelings towards a patient may result in diagnoses being missed
- common types: non-compliant patients, homeless, patients with chronic pain especially those requesting an opioid, obese patients, patients with alcohol on their breath, patients of different background
satisfaction of search?
you’re tired, under pressure, it’s hard to think of other diagnoses
- you find one answer that explains all of the data, your’e satisfied and stop examining alternatives
- Ockham’s razor - the simplest explanation is usually the correct one
how to proceed?
select working diagnosis and proceed with plan, remember to follow up with others on differential, be open to change
requirements for diagnostic accuracy & efficiency
- depth of medical knowledge
- complete yet concise case representation
- identification of salient features
- make diagnosis
fast thinking processes for diagnosing?
- intuitive - passive - unconscious, instinctual
- pattern recognition
- contextual
- based on prior experience (exposures)
- options considered are limited
- high risk of error (atypical presentation, missing cardinal symptom)
slow thinking processes for diagnosing
- deliberative - active, stepwise
- analysis of data available
- logical, rule based
- based on critical thinking
- larger number of options considered
- low risk of error
heuristic cognitive style?
intuitive
systematic thinking style
analytical
potential pitfalls to diagnosing
PREMATURE CLOSURE - accept a diagnosis at face value without looking for further evidence to confirm or refute
AVAILABILITY ERRORS: tendency to accept a diagnosis because of past similar events
BASE RATE NEGLECT: more esoteric diagnoses are favored over more common diagnosis
REPRESENTATIENESS: tendency to be guided by the typical presentation of a disease and miss atypical variants
CONFIRMATION BIAS: tendency to seek and use data to confirm and not refute a diagnosis
what should you think about regarding epidemiology?
demographics (age/gender/race/ethnicity); risk factors (genetics/predisposing conditions); exposures (travel/occupation/activities/hobbies/physical activities/lifestyle/food/drugs/toxins); close contacts (living situation people/pets, sexual activities)
hyperacute?
minutes to hours
acute?
days
sub acute
weeks
chronic
weeks
time course/pattern
duration - persistence
constancy - stable or progressing
episodic - waxing/waning; biphasic; intermittent
what 3 things do you need in a patient illness script?
epidemiology, time course, signs/symptoms
VINDICATE as a universal mnemonic for differential diagnosis
Vascular Inflammatory Neoplastic Degenerative/Deficiency Idiopathic/intoxication Congenital Autoimmune/Allergic Traumatic Endocrine
