By Shira Sachs MD, Stephanie Sherman MD, Cindy Fang MD and John Hwang MD || Audio Editing by Richard Chen || Graphic by Amy Ou MD

Time Stamps



* Player three has entered the game! [0:15 ]

* Case presentation, part 1 [1:20 ]

* First impressions [3:24 ]

* Rethinking another provider’s diagnosis [4:36 ]

* Interpreting the test of treatment [9:42 ]

* Keeping your instincts on a leash? [10:58 ]

* Case presentation, part 2 [12:33 ]

* Diagnostic schemas [14:30 ]

* Our discussant’s differential and the final diagnosis [17:46 ]

* Shira’s cognitive autopsy [23:02 ]



Show Notes



* “Diagnostic momentum” refers to our conscious or unconscious tendency to avoid rethinking a diagnosis that has already been “assigned” to a patient.



* While most diagnoses made by doctors are correct, many are not.

* Since it is often impractical to comprehensively question every assigned diagnosis, learning to recognize when these labels do not fit the patient is an essential skill.









* The test of treatment is a legitimate diagnostic tool, but like any test, it can produce false positive and false negative results.



* False positive: A doctor may misdiagnose angina if her patient’s chest pain improves with nitroglycerin, when in fact it remitted spontaneously.

* False negative: A patient with obstructive sleep apnea may complain of persistent symptoms despite positive airway pressure, when in fact the prescribed settings may simply be insufficient.









* The term “diagnostic schema” describes a clinician’s structured approach to a recurring clinical problem.



* Experts have robust schema for problems within their discipline, which enable them to dissect cases featuring these problems efficiently and accurately.

* Extensive reading and deliberate clinical practice are needed to refine the schema we “inherit” from our medical training as novices (e.g. “pre-renal, intrinsic, and post-renal causes of acute kidney injury).









* The cognitive autopsy is a self-reflection exercise in which the clinician retrospectively interrogates their thought process to identify cognitive errors and areas for improvement in their reasoning.



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Transcript

CINDY Hey everyone, Cindy Fang here. Thanks for tuning in. And we have something new for you this month.



JOHN Someone new, rather. Hoofbeats listeners: meet Dr. Shira Sachs.



SHIRA What’s up, guys?



JOHN So, Shira, welcome — it’s so great to have you. Can we have you tell our listeners a bit about yourself?



SHIRA For sure, it’s great to be here. So I recently moved here from Houston, Texas, where I did my residency and a chief year, after which I worked as a hospitalist for a year down at Baylor, and I just moved to New York in July and have been a hospitalist at Cornell since then, as a part of the hospital medicine fellowship medicine program there, the clinical scholars program.



JOHN Well, it’s a real privilege to have you here.



CINDY And Shira came to us with a case that we think you’ll really enjoy.



SHIRA Yeah, today we’re going to reason through a great case I saw on wards with my team a few months ago.