DB'S MEDICAL RANTS

Internal medicine, American health care, and especially medical education

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How guidelines and performance measures can increase diagnostic errors!

Next Tuesday I will give my latest version of the sore throat grand rounds.  As I wrote last week, my colleagues exposed me to the dual process theory of clinical reasoning.  As I have read more about this cognitive theory, several insights have blossomed.  My new grand rounds title is “Clinical Reasoning: Lessons from Studying Pharyngitis”.

To recap an earlier post, physicians probably use two types of reasoning – intuitive (or automatic or simple) and analytic (or complex).  Intuitive reasoning solves most problems very well, and because intuitive reasoning takes little time, we favor its use.  However, some problems require analytic reasoning.  One key to expertise is knowing when to switch from intuitive reasoning to analytic reasoning.  In my previous post, I featured the concept of slowing down.  That author (and she has convinced me) argues that experts differ from experienced non-experts because they more often know to slow down and switch to analytic reasoning.

Pharyngitis guidelines (and performance measures) focus solely on acute pharyngitis and whether or not the patient has streptococcal pharyngitis.  This framing (also known as an illness script) pervades the literature.

The problem is in the problem representation.  If we stop our history taking at the words “sore throat”, then we accept the term “Just a sore throat”.  This thinking is seductive, because often this short cut works.  Most sore throats are unimportant.  Our guidelines and performance measures focus on the short head of sore throats and ignore the long tail.

Lorber and Fekete wrote about this problem in The Pharos – Community-acquired pneumonia: the tyranny of a term.  In that article, they present a patient incorrectly diagnosed and treated for CAP.  They make several wonderful points in that article.  The point they do not make is that performance measures and guidelines emphasize CAP.  Our well-meaning experts, by emphasizing this term, have stifled careful thinking.

My grand rounds includes the CAP example, and then focuses on what is NOT “just a sore throat”.

Here is point – expertise requires us to be certain about our diagnoses.  We should not use short cuts, or at least know the contextual implications of those short cuts.

“Community acquired pneumonia” should not be a waste basket for anyone with fever, cough and an abnormal CXR.  We need to understand that CAP has a short time frame and several associated symptoms.

Similarly “just a sore throat” has a very short time frame.  Significant sweats or rigors are not part of “just a sore throat”.  Unilateral neck swelling is not a component.  Symptom duration longer than 5 days is not a component.

Our guidelines and performance measures may overemphasize these tyrannical terms.  We in medical education must provide the context.  Guideline developers should note this problem and provide appropriate disclaimers and counter examples.

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