Discover and read the best of Twitter Threads about #ClinicalReasoning
Most recents (19)
Expert clinicians utilize targeted debiasing strategies almost instinctively
@rabihmgeha at #SGIM23 employing “What can’t I explain?” for a pt w “CHF exacerbation” hypoxic to 70% on RA, improved to 92% on 3L
Photo from my recent Cognitive M&M courtesy of @UABMedPeds @uabimres
@rabihmgeha at #SGIM23 employing “What can’t I explain?” for a pt w “CHF exacerbation” hypoxic to 70% on RA, improved to 92% on 3L
Photo from my recent Cognitive M&M courtesy of @UABMedPeds @uabimres
He emphasized: the crux of the case probably lies in this one point.
That you went from “may need to intubate” to “looks great” with only 3Lnc?
Doesn’t add up…
Consider an alternative etiology for his hypoxemia — notably, w such profound response to minimal O2, hypercarbia
That you went from “may need to intubate” to “looks great” with only 3Lnc?
Doesn’t add up…
Consider an alternative etiology for his hypoxemia — notably, w such profound response to minimal O2, hypercarbia
Spot on, as always!
Pt admitted for diuresis. Became progressively somnolent - gas showed marked respiratory acidosis, CTH w cerebral edema — all d/t hypercarbia 2/2 OSA
So. Anytime I utilize “What can’t I explain?” in a diagnostic timeout, I create a new brief script.
Pt admitted for diuresis. Became progressively somnolent - gas showed marked respiratory acidosis, CTH w cerebral edema — all d/t hypercarbia 2/2 OSA
So. Anytime I utilize “What can’t I explain?” in a diagnostic timeout, I create a new brief script.
Formulating and appraising your PR (problem representation) is critical to the diagnostic process, and intrinsically welcomes cognitive bias
Work this case with me #MedTwitter
ED calls for admission: “40yo M w pneumonia”
*fist pump* sweet, easy admission
1/
Work this case with me #MedTwitter
ED calls for admission: “40yo M w pneumonia”
*fist pump* sweet, easy admission
1/
“Fever, cough, dyspnea x2d. WBC 20, triggered sepsis. Got cx, fluids, abx. CXR RLL infiltrate. Needs admission for sepsis 2/2 CAP”
With that PR, slam dunk pneumonia.
100% match for my CAP illness script, don’t even need my dyspnea schema (courtesy of @DxRxEdu @CPSolvers)
With that PR, slam dunk pneumonia.
100% match for my CAP illness script, don’t even need my dyspnea schema (courtesy of @DxRxEdu @CPSolvers)
#CognitiveBias of premature closure
+
cognitive load of retaking a full hx on such an “easy admission” 12hrs into call
=
Cutting corners in the name of “efficiency”
So you confirm a preconceived HPI
Fever✅
Cough✅
Leukocytosis✅
CXR infiltrate✅
Community acquired PNA✅
2/
+
cognitive load of retaking a full hx on such an “easy admission” 12hrs into call
=
Cutting corners in the name of “efficiency”
So you confirm a preconceived HPI
Fever✅
Cough✅
Leukocytosis✅
CXR infiltrate✅
Community acquired PNA✅
2/
This just out: Physicians do not logically/correctly estimate the probability of outcomes resulting from sequences of events - a thread. #conjunctionfallacy #probability #medicaldecisionmaking #clinicalreasoning #innumeracy #numeracy jamanetwork.com/journals/jaman… @JAMANetworkOpen
In this article, we showed that physicians estimated the probability of two events both occurring as *more* likely than one or both of the individual events. This is logically impossible and consistent with the #conjunctionfallacy. This #bias can lead to catastrophic outcomes
The impetus for the study was an #OBGYN catastrophe that resulted, in part, from this bias. A woman presented in labor w brow presentation. For successful vaginal delivery, 2 events must happen: reversion to deliverable position, and vaginal delivery w/o #caesareansection
#Medtwitter, last week I posted about a talk I gave on teaching #clinicalreasoning
As promised, the accompanying #tweetorial
Come explore with me!
1/10
As promised, the accompanying #tweetorial
Come explore with me!
1/10
I described a gap between DOING and TEACHING reasoning
All of us DO reasoning every day
TEACHING what we DO is hard unless we
✔️have vocabulary to describe it
✔️know how to describe a process
✔️are ok being vulnerable in front of others
2/10
All of us DO reasoning every day
TEACHING what we DO is hard unless we
✔️have vocabulary to describe it
✔️know how to describe a process
✔️are ok being vulnerable in front of others
2/10
How do we make an invisible process (reasoning), visible?
Step 1: use specific words to describe steps to the cognitive process:
Problem representation
Schema
Illness scripts
Speaking these words signals their importance to your learners - use them!
3/10
Step 1: use specific words to describe steps to the cognitive process:
Problem representation
Schema
Illness scripts
Speaking these words signals their importance to your learners - use them!
3/10
Today, I gave a new version of a talk I do on teaching clinical reasoning that focused on the gap between DOING reasoning and TEACHING reasoning
I identified some of the challenges offered some suggestions to overcome them
#MedTwitter #clinicalreasoning
I identified some of the challenges offered some suggestions to overcome them
#MedTwitter #clinicalreasoning
The gap is big and the solutions are many
What I spoke about represents an evolution in my understanding gained through great mentorship and friends
Grateful I had the chance to share what I've learned 🙏🙏🙏
Hit me up if ur program would like to hear it!
What I spoke about represents an evolution in my understanding gained through great mentorship and friends
Grateful I had the chance to share what I've learned 🙏🙏🙏
Hit me up if ur program would like to hear it!
@MohitHarshMD @SatyaPatelMD @rav7ks @jackpenner @Anand_88_Patel @DoctorVig @andrewolsonmd @thilanMD @AnnKumfer @medrants Thanks everyone for the love and kind words! I'll turn this into a tweetorial next week. Happy to give this talk virtually as well!
I’m in a graveyard.
Why?
#Risk #CervicalSpine #VertebralArtery #Physiotherapy #PhysicalTherapy
Part III - Risk Assessment of The Cervical Spine
... coming VERY soon! 👀
Why?
#Risk #CervicalSpine #VertebralArtery #Physiotherapy #PhysicalTherapy
Part III - Risk Assessment of The Cervical Spine
... coming VERY soon! 👀
Part III - Risk Assessment of The Cervical Spine: Directions For The Future
If the vertebral artery test truly is dead (?), where do we go from here?
#CervicalSpine #RiskAssessment #FCP #Physiotherapy #PhysicalTherapy #ClinicalReasoning #Haemodynamics
If the vertebral artery test truly is dead (?), where do we go from here?
#CervicalSpine #RiskAssessment #FCP #Physiotherapy #PhysicalTherapy #ClinicalReasoning #Haemodynamics
Thanks to @RikKranenburg @NathanHutting @RogerKerry1 and the Australian Physiotherapy Association for providing me with the impetus to think about, and produce these short films. #Haemodynamics #RiskAssessment #CervicalSpine #FCP #Physiotherapy #PhysicalTherapy #Education
Risk Assessment of the cervical spine for NON-MANUAL THERAPISTS
4 case scenarios, to problem solve #RISK in the assessment & management of neck pain presentations.
#ClinicalReasoning #Physiotherapy #PhysicalTherapy #FCP #Haemodynamics #VertebralArtery
4 case scenarios, to problem solve #RISK in the assessment & management of neck pain presentations.
#ClinicalReasoning #Physiotherapy #PhysicalTherapy #FCP #Haemodynamics #VertebralArtery
Case 1.
Mayumi a 69 year old male archer (retired factory worker).
#ClinicalReasoning #FCP #Physiotherapy #PhysicalTherapy #Haemodynamics
Mayumi a 69 year old male archer (retired factory worker).
#ClinicalReasoning #FCP #Physiotherapy #PhysicalTherapy #Haemodynamics
Case 2.
Phil a 41 year male sports shop proprietor and ex-olympic rower.
#ClinicalReasoning #FCP #Physiotherapy #PhysicalTherapy #Haemodynamics
Phil a 41 year male sports shop proprietor and ex-olympic rower.
#ClinicalReasoning #FCP #Physiotherapy #PhysicalTherapy #Haemodynamics
1 Let’s talk #toxicology! Dr. Kelly Sopko @kelly_sopko shared a RIVETING case of a patient with frequent readmissions, now presenting with agitated delirium and admitted for cough + suspect ETOH intoxication. A curiously broad Ddx! (thread) #clinicalreasoning #medtwitter #MedEd
2 70 year old M PMH bipolar disorder, chronic low back pain, 17 readmits over past 1 year, presents with cough, requesting detox and develops worsening agitation after a dose of ativan given in ED. Thoughts, @VUMCInternalMed and #medtwitter? @VUMCHospitalMed team-generated ddx:
3 Initial labs found here. Anything stand out? Are you impressed? This is from the pre-#COVID19 era, mind you:
1/ Do you mentor or are you: a learner wanting to improve exam scores? Dx the reason for low test scores in today’s #MedEdMethodsMonday!
Inspired by @thecurbsiders ep193 featuring @Missydoc0128
#MedEd #MedThread #MedEdPearl #MedTweetorial #FacDev #Medtwitter #medstudenttwitter
Inspired by @thecurbsiders ep193 featuring @Missydoc0128
#MedEd #MedThread #MedEdPearl #MedTweetorial #FacDev #Medtwitter #medstudenttwitter
2/ Self-Regulated Learning Microanalytic Assessment and Training (SRL-MAT) - a tool that can identify 6 test-taking problems, described by Dr. Andrews @williamkellymd @GenesseyFlint & Dr. Dezee from @USUhealthsci in @AcadMedJournal
tiny.cc/SRLtool
tiny.cc/SRLtool
3/ The tool is used between a mentor & learner in a 60-min session.
The learner 1st reads & thinks aloud while going through a vignette appropriate for their level, with the actual question and answers covered.
They then talk through a Question Review Form:
The learner 1st reads & thinks aloud while going through a vignette appropriate for their level, with the actual question and answers covered.
They then talk through a Question Review Form:
#ACPOR19 Dr. Jacque Levene presenting her oral clinical vignette!
#acpor19 rocking an enabling hypothesis-driven differential diagnosis! #clinicalreasoning #diagnosticreasoning
#ACPOR19 it’s all about the problem statements and the Illness scripts
1/ #MedTwitter, it’s time for #ClinicalReasoning practice with Bayes’ Theorem!
Follow along and let us know what you’re thinking!
72-yo-woman with HTN, DM, & knee replacement (10 days ago) p/w pleuritic chest pain, dyspnea and cough.
Follow along and let us know what you’re thinking!
72-yo-woman with HTN, DM, & knee replacement (10 days ago) p/w pleuritic chest pain, dyspnea and cough.
2/ As you walk down to the ER, you have diagnoses in your mind that are somewhere between unlikely and very likely.
This likelihood is known as:
This likelihood is known as:
3/ ANS: Pretest probability
On exam, her temperature is 100.1F, HR 108 and SaO2 88% RA. Her lower extremities are without swelling, tenderness, or erythema.
Basic labs are in process. What else would you order?
We’d love to see your reasoning in the replies!
On exam, her temperature is 100.1F, HR 108 and SaO2 88% RA. Her lower extremities are without swelling, tenderness, or erythema.
Basic labs are in process. What else would you order?
We’d love to see your reasoning in the replies!
1/
A TALE OF TWO STENTS
a #twitternist #clinicalreasoning and #implicitbias reflection
Wanted to share 2vignettes with you #medtwitter, w permission (identities, some details changed)
Both involve rapid thinking, stretched foci of attention, unanticipated clinical events->
A TALE OF TWO STENTS
a #twitternist #clinicalreasoning and #implicitbias reflection
Wanted to share 2vignettes with you #medtwitter, w permission (identities, some details changed)
Both involve rapid thinking, stretched foci of attention, unanticipated clinical events->
2/ first vignette :
Seeing last pt in morning session, 45 mins back
Finishing up, see another pt’s e mail & message on desk phone
Need 2finish up w pt in front of me, but odd message left in both places
Call back - 72 yo man, remote preDM but got that BMI to 23 long ago, ->
Seeing last pt in morning session, 45 mins back
Finishing up, see another pt’s e mail & message on desk phone
Need 2finish up w pt in front of me, but odd message left in both places
Call back - 72 yo man, remote preDM but got that BMI to 23 long ago, ->
3/ mild lipids on lo dose statin, chronic bronciectasis, reflux. Know him 15 yrs as pt.
Pt: Dr. C, I feel better now, but ..(uh oh) when I woke had a discomfort in my L neck, felt sweaty. That’s all gone for a few hours now, I think I’m fine. But I don’t have my appetite ->
Pt: Dr. C, I feel better now, but ..(uh oh) when I woke had a discomfort in my L neck, felt sweaty. That’s all gone for a few hours now, I think I’m fine. But I don’t have my appetite ->
I had a bit of an “ah ha moment” while attending in our #dermatology resident clinic a month ago.
The way I run this clinic means that when the timing is right, I try to have our senior resident precept the junior resident. I try to stay silent and literally say nothing.
1/
The way I run this clinic means that when the timing is right, I try to have our senior resident precept the junior resident. I try to stay silent and literally say nothing.
1/
When this happened, we had a brand new senior and a brand new first year. Essentially both residents were settling into their respective roles.
In typical fashion, the junior resident presented the key points to the senior resident as I listened on.
2/
In typical fashion, the junior resident presented the key points to the senior resident as I listened on.
2/
Jr: the patient doesn’t have a rash today, but the pictures look like wheals. He says that pressure causes it. Diphenhydramine doesn’t work that well. He doesn’t have dermatographism.
Sr: what do you think it is?
::both look at me to see what I’m thinking/about to say::
3/
Sr: what do you think it is?
::both look at me to see what I’m thinking/about to say::
3/
1/ A quick glance at the foot of the bed unravels a rare answer to a common complaint... another #tweetorial to sharpen our #clinicalreasoning skills, #medtwitter! Try to solve this mystery case and see if you can... nail it!
2/ A 58 year-old man presented with gradual, progressive dyspnea. Two months ago he had no trouble ambulating, now he is limited to several blocks.
3/ Take a mental pause here to practice how you might approach “dyspnea”, and then listen to @BBroderickMD take us through it: bit.ly/32fCXXr
It's time for #TwitterReport! Get out your illness scripts and problem representations.
Case: A 65yoM with metastatic melanoma goes to the ER with RLE edema: doppler shows a femoral DVT. He also says he's been getting more tired over the last 4wk.
What else do you want to know?
Case: A 65yoM with metastatic melanoma goes to the ER with RLE edema: doppler shows a femoral DVT. He also says he's been getting more tired over the last 4wk.
What else do you want to know?
PMH: HTN, HL, T2DM (now diet controlled), metastatic melanoma
PSH: none
Meds: HCTZ, metoprolol, atorvastatin, pembrolizumab/ipilimumab (last cycle 2 weeks ago)
Social: lives with wife and dog at home. From a local rural area. Never smoker/alcohol. Former construction worker.
PSH: none
Meds: HCTZ, metoprolol, atorvastatin, pembrolizumab/ipilimumab (last cycle 2 weeks ago)
Social: lives with wife and dog at home. From a local rural area. Never smoker/alcohol. Former construction worker.
ER Triage Vitals:
-Temp 37*C
-HR 60
-BP 90/54
-RR 12
-SpO2 98% on room air
What else do you want to know?
-Temp 37*C
-HR 60
-BP 90/54
-RR 12
-SpO2 98% on room air
What else do you want to know?
1) aim to “understand deeply.” Admitting that you don’t understand puts you in a mind-set to learn
2)”fail effectively.” Try & falter-learn a little each time you don’t succeed
3) create questions.” Think slowly through specifics that challenge you getabstract.com/en/summary/mak…
2)”fail effectively.” Try & falter-learn a little each time you don’t succeed
3) create questions.” Think slowly through specifics that challenge you getabstract.com/en/summary/mak…
4) “go w/ the flow of ideas.” Connect your thinking. Think through a topic to connect it with other disciplines, ideas and subjects
5) be open to change.” Keep an open mind; be willing to see things differently
Take charge of your learning; don’t wait for others to educate you!
5) be open to change.” Keep an open mind; be willing to see things differently
Take charge of your learning; don’t wait for others to educate you!
1/Hey, #medtwitter, bust out your schemas - it's time for another CPSers tweetorial! #FOAMed #clinicalreasoning #medthread
2/A 46F presented with 2 weeks of diffuse abdominal pain, nausea and vomiting. Pause and reflect on how you’d approach her abdominal pain, and then check out this schema: clinicalproblemsolving.com/dx-schema-abdo…
3/On exam, her VS were T 36.2C BP 178/100 HR 82 and RR 16. She had sclerodactyly as well as shiny/thickened skin over her face, arms, and chest with telangiectasias. There was 2+ pitting BLE edema.
An 85M with ischemic cardiomyopathy (EF 20%) with an AICD for primary prevention presents with a syncopal episode. Pause and think of your schema for syncope, and then check out this approach by @StephVSherman from @BCM_InternalMed
clinicalproblemsolving.com/dx-schema-sync…
clinicalproblemsolving.com/dx-schema-sync…
He reports feeling lightheaded with standing and exertion for the last few weeks. His partner witnessed him lose consciousness for about one minute after getting out of bed this morning. Pause and think of your 4 common syncope mimics...
#MedThread on #ClinicalReasoning
@medicalaxioms and co made a great list👇 of routinely missed/delayed diagnoses.
Theme: uncommon conditions that present with common/non-specific symptoms.
How can we make these dx sooner without overtesting?
@medicalaxioms and co made a great list👇 of routinely missed/delayed diagnoses.
Theme: uncommon conditions that present with common/non-specific symptoms.
How can we make these dx sooner without overtesting?
X/ Goal is to arrive at the appropriate pre-test probability with the fewest/least expensive/least harmful tests possible, and end up on the right side of the testing threshold of the expensive/risky but more “definitive” test.
X/ By the way: “test” in this thread refers not only to labs and imaging but also to history questions, exam maneuvers, etc
