A 48-year-old man, previously healthy, presented to the emergency department after a sudden episode of cough, dyspnea, and a sensation of chest

Transcription

1 A 48-year-old man, previously healthy, presented to the emergency department after a sudden episode of cough, dyspnea, and a sensation of chest tightness that happened while he was climbing the stairs in his apartment. The patient reports two similar episodes during the last month, one when he was cutting threes in the garden and the other while he was repairing a sport court. In all occasions, the symptoms stopped spontaneously in a few hours, without any other intervention besides resting. Between the episodes, the patient felt well, without noticing restrictions to physical exercises. He smoked 30 cigarettes per day during around 20 years, but stopped completely 3 years ago. He does not use any medication and there is no history of allergy. Family history: His father died due to myocardial infarction when he was 60. Physical examination: BP: 120/80mmHg Pulse: 90 bpm Temp: 36,50 o C Respiratory: 20rpm Patient appeared healthy but in respiratory distress. Jugular veins: no abnormalities. Heart: auscultation without abnormalities. Lungs: bilateral ronchi and wheezes. No other abnormalities in the physical examination. Laboratory data: Ht: 45%; Leukocytes: 13,5 x 10 9 /L, 82% neutrophils, 11% lymphocytes, 5% monocytes, 2% eosinophyl. Electrolytes, ureum, kreatinine, glucose: values within normal range. Blood gases (patient breathing environmental air) - po2: 6,9 kpa, pco2: 4,6 kpa, ph: ECG: without abnormalities except non-specific alterations in the ST-segment and T waves. Blood gases in a subsequent measurement (patient breathing environmental air), after symptoms remission - po2: 13,5 kpa, pco2: 4.3 kpa, ph: X-Ray: Thorax: normal cardiac area, clear lung fields. No signs of congestive cardiac insufficiency.

2 For Better or Worse: Context Influences Diagnostic Accuracy Silvia Mamede, Jerome Rotgans, Tamara van Gog, Lucy Rosby, Martine Chamberland, Remy Rikers, Laura Zwaan, Jan van Saase, Ted Splinter, Henk Schmidt Erasmus University, the Netherlands, and LKC Medicine, NTU, Singapore

3 A 48-year-old man, previously healthy, presented to the emergency department after a sudden episode of cough, dyspnea, and a sensation of chest tightness that happened while he was climbing the stairs in his apartment. The patient reports two similar episodes during the last month, one when he was cutting threes in the garden and the other while he was repairing a sport court. In all occasions, the symptoms stopped spontaneously in a few hours, without any other intervention besides resting. Between the episodes, the patient felt well, without noticing restrictions to physical exercises. He smoked 30 cigarettes per day during around 20 years, but stopped completely 3 years ago. He does not use any medication and there is no history of allergy. Family history: His father died due to myocardial infarction when he was 60. Physical examination: BP: 120/80mmHg Pulse: 90 bpm Temp: 36,50 o C Respiratory: 20rpm Patient appeared healthy but in respiratory distress. Jugular veins: no abnormalities. Heart: auscultation without abnormalities. Lungs: bilateral ronchi and wheezes. No other abnormalities in the physical examination. Laboratory data: Ht: 45%; Leukocytes: 13,5 x 10 9 /L, 82% neutrophils, 11% lymphocytes, 5% monocytes, 2% eosinophyl. Electrolytes, ureum, kreatinine, glucose: values within normal range. Blood gases (patient breathing environmental air) - po2: 6,9 kpa, pco2: 4,6 kpa, ph: ECG: without abnormalities except non-specific alterations in the ST-segment and T waves. Blood gases in a subsequent measurement (patient breathing environmental air), after symptoms remission - po2: 13,5 kpa, pco2: 4.3 kpa, ph: X-Ray: Thorax: normal cardiac area, clear lung fields. No signs of congestive cardiac insufficiency.

4 Deliberate Reflection Instructions to participants: Read the case and provide a diagnostic hypothesis Which signs and symptoms support your diagnostic hypothesis (H)? List them! Which signs and symptoms do not support your H? List them! Which cues should have been there if your H is correct and are not? List them! Do you have an alternative H? If so: start over. What is your final diagnosis?

5 Diagnostic hypothesis 1 Asthma 3 2 Chronic obstructive pulmonary disease (COPD) Pulmonary embolism Findings that speak in favor of this diagnostic hypothesis Chest tightness Dyspnea Cough Wheezing Attacks after exercise or exposure to allergens Remission of symptoms Hypoxemia Attacks triggerred by exercise Age of onset middle-age Long time smoker Dyspnea Rhonchi Wheezing Hypoxemia Dyspnea Wheezing Chest tightness ECG Smoker Findings that speak against this diagnostic hypothesis Age of onset Without history of allergy No family history of asthma Dyspnea and cough: episodic Non-pleuritic chest pain (tightness) Normal respiratory frequency Jugular veins: no abnormalities X-Ray without abnormalities Findings expected to be present, but not described in the case Accessory muscles use Prolongation of expiratory phase Sputum production Chronic, persistent cough Respiratory acidosis Decreased breath sounds Tachypnea Hemoptysis History of risk factors for DVT (immobilization etc.)

6 Diagnostic hypothesis 1 Asthma 3 2 Chronic obstructive pulmonary disease (COPD) Pulmonary embolism Findings that speak in favor of this diagnostic hypothesis Chest tightness Dyspnea Cough Wheezing Attacks after exercise or exposure to allergens Remission of symptoms Hypoxemia Attacks triggerred by exercise Age of onset middle-age Long time smoker Dyspnea Rhonchi Wheezing Hypoxemia Dyspnea Wheezing Chest tightness ECG Smoker Findings that speak against this diagnostic hypothesis Age of onset Without history of allergy No family history of asthma Dyspnea and cough: episodic Non-pleuritic chest pain (tightness) Normal respiratory frequency Jugular veins: no abnormalities X-Ray without abnormalities Findings expected to be present, but not described in the case Accessory muscles use Prolongation of expiratory phase Sputum production Chronic, persistent cough Respiratory acidosis Decreased breath sounds Tachypnea Hemoptysis History of risk factors for DVT (immobilization etc.)

7 Diagnostic hypothesis 1 Asthma 3 2 Chronic obstructive pulmonary disease (COPD) Pulmonary embolism Findings that speak in favor of this diagnostic hypothesis Chest tightness Dyspnea Cough Wheezing Attacks after exercise or exposure to allergens Remission of symptoms Hypoxemia Attacks triggerred by exercise Age of onset middle-age Long time smoker Dyspnea Rhonchi Wheezing Hypoxemia Dyspnea Wheezing Chest tightness ECG Smoker Findings that speak against this diagnostic hypothesis Age of onset Without history of allergy No family history of asthma Dyspnea and cough: episodic Non-pleuritic chest pain (tightness) Normal respiratory frequency Jugular veins: no abnormalities X-Ray without abnormalities Findings expected to be present, but not described in the case Accessory muscles use Prolongation of expiratory phase Sputum production Chronic, persistent cough Respiratory acidosis Decreased breath sounds Tachypnea Hemoptysis History of risk factors for DVT (immobilization etc.)

8 Two Modes of Thought: System 1 and System 2 System 1 System 2 pattern recognition thoughtful analysis of symptoms automatic deliberate inflexible flexible effortless effortful requires no attention requires conscious attention is fast is slow activated in limbic system activated in frontal cortex

9 Hippocampus plaatje

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12 F-NIRS

13 Accuracy and time needed

14 Stimulus presentation (1.00) (2.00) (3.00) oxy-hb untrained oxy-hb trained

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16 System 2 thinking in experts: Good or bad? * Simple cases Complex cases 1. Aortic dissection 1. Addison s disease and tuberculosis 2. Acute endocarditis 2. Acute salpingitis with perihepatitis 3. Lung cancer 3. Pneumonia with sepsis 4. Sarcoidosis 4. Appendicitis with perforation 5. Inflammatory bowel disease 5. Necrotizing fasciitis 6. Stomach carcinoma 6. Acute myocardial infarction and subarachnoid haemorrhage 7. Cushing s disease 7. Claudicatio due to occlusive arterial disease 8. Systemic lupus erythematosus 8. Non-Hodgkin s lymphoma with hemolytic anemia * Medical Education, 2008, 42,

17 System 2 thinking in professionals: Good or bad?

18 System 2 thinking in professionals: Good or bad? * Simple cases Complex cases Automatic Reflective

19 What causes doctors to shift from System 1 to System 2? Perceived difficulty* 1. Acute bacterial endocarditis 2. Inflammatory bowel disease 3. Acute viral hepatitis 4. Acute bacterial meningitis 5. Hyperthyroidism 6. Deficiency of Vitamin B Addison s disease 8. Celiac disease 9. Acute myeloid leukemia 10. Acute appendicitis *Academic Medicine, 2008, 83,

20 Time needed Average time needed to diagnose Non-problematic context Problematic context

21 Confidence in decision Confidence in diagnosis Non-problematic context Problematic context

22 Complexity judgment Confidence in diagnosis Perceived case complexity Non-problematic context Problematic context

23 Prior experience judgment Confidence in diagnosis Perceived case complexity Frequency of similar cases seen Non-problematic context Problematic context

24 Diagnostic accuracy Diagnostic accuracy Diagnostic accuracy Non-problematic context Problematic context

25 Difficult patients* Residents were presented with simple and complex cases In a within-subjects design they received the same cases either in a difficult patient version or a more neutral version *BMJ Quality and Safety, 2016

26 Difficult patients Difficult patient version A 63-year-old male arrives at the emergency room with intense precordial pain and sweating. He arrives making fuzz because he had to wait too long for the ambulance to arrive, and the IV was obviously incorrectly put. He rebukes the paramedics and when you approach him you are received with a A resident, what an honour! Why don t you get your boss directly? He is a civil servant, is married and has no children. He has had a history of coronary disease and. Neutral version A 63-year-old male arrives at the emergency room with intense precordial pain and sweating. He seems a bit tense at presentation and says that he is indeed always nervous when coming to hospitals but feels more comfortable, because he was well treated by the paramedics. You shake his hand he seems to feel relieved because you have come to see him immediately. He is a civil servant, is married and has no children. He has had a history of coronary disease and.

27 Effects of difficult patients on diagnostic accuracy Difficult patient version Neutral version Easy cases Complex cases.23.40

28 Information recalled from cases

29 Is it possible to study bias in clinical reasoning?

30 Tunnel vision: the inability to abandon a preconceived idea

31 Rabbit

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33 Availability bias provoked by Wikipedia* 38 residents in internal medicine Evaluate accuracy of Wikipedia information either about Q fever or Legionnaires disease *Academic Medicine, 2014, 89(2):285-91

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35 Availability bias provoked by Wikipedia* 38 residents in internal medicine Evaluate accuracy of Wikipedia information either about Q fever or Legionnaires disease 6 hours later: Diagnose 8 clinical cases, 4 of which resembled Q fever or Legionnaires disease Reflect on initial diagnosis *Academic Medicine, 2014, 89(2):285-91

36 Diagnostic accuracy biased by Wikipedia Cases solved after exposure to the Wikipedia information Cases solved without exposure to the Wikipedia information Phase 2 (non-analytical reasoning) Phase 3 (reflective reasoning) _

37 Availability bias caused by patients previously seen* 1 st -year and 2 nd -year residents Phase 1. Evaluation of diagnoses for 2 cases Phase 2. Diagnosis of 4 look-alike cases embedded in fillers Phase 3. Reflective reasoning about the 4 cases * JAMA, 2010, 304(11),

38 Cases used in availability bias study

39 2.5 2nd-year AIOS nd-year AIOS Previous experiences Without experiences

40 st-year AIOS 2nd-year AIOS Previous experiences Without experiences

41 st-year AIOS 2nd-year AIOS Non-analytical reasoning Reflective reasoning

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43 Time pressure* Residents were presented with eight fairly complex cases Half of them processed the cases at their own pace The other half was instructed to imagine that they worked in a busy outpatient clinic and had to work quickly After each case the latter received feedback indicating that they were lagging behind *Academic medicine, 2016

44 Feedback after 7 th case

45 Amount of time used

46 Diagnostic accuracy under time pressure

47 Structure of an illness script

48 A Patient

49 The Green Card 57

50 A Complaint Doctor, I had such a high fever last night that I was in my bed shaking violently!

51 Role of context in expertise (Hobus et al, 1995)

52 Role of context in expertise (Hobus et al, 1995)