DIP Episode 275 - USMLE Nov 2020 Changes Series 5: Diagnostic Errors

Welcome. My name is Devine. This is the next episode of the Divine Intervention Podcast. I'm pretty sure this is episode 275. And in this episode I'm going to be discussing, continuing the series on the USMELI content changes. Right? So we all know that step to CK. They meet some content changes on the 11th of November. And so far, you know, like healthcare systems, professionalism, communication, ethics and all those things. Already have a few podcasts that address some of these changes in terms of content. Right? So I do have four podcasts actually that I've made specifically on the new content that's been tested. For those of you that are interested, that's going to be episode 228. That series won. Talks about palliative care. And then there is episode 230. And then that series two. There's episode 234. That series three. And then there's episode 268. That series four. So today will be series five. And today in today's series, and also have an ethics podcast, by the way. A lot of people, they get a lot of ethics questions on the new example. I do actually have an ethics podcast. So that's something you want to look into as well. I believe it's episode 120 something. And then again, for those of you that are preparing for step two, CK, I will encourage you to not just listen to the RAPRI to review series. Typically, I would recommend that your first starting point should be the mainstream review videos. So like I have like a video for peeds, video for surgery.

I have four videos for I am. I have a video for psych, a video for OB guy. I have eight audio podcasts for near those things that the more comprehensive reviews, right? The rapid reviews are called rapid reviews for a reason. They're very great. They've helped a ton of people on exams. But they're like just integrations of many different concepts from many different fields. So if you have like a bona fide dedicated period for step two, CK, what I will strongly encourage you to do in terms of approaches start off by watching the mainstream videos following along with the slides that I have for those. And then after that, you then start pounding through the rapid review series. And then obviously you're going to be doing a Q bank, but also at the same time, you should also be doing some of those MBME practice of exam questions. So I think that's the advice I will give recommendation. I will give in terms of preparing for for the exam. And then obviously I also have this whole special topic section. If you look at the spreadsheet on the website, but I like some key topics, right? So like I have like a podcast on an EMI is have a podcast on iron labs have a podcast on vitamins, right? Those are just kind of like podcasts where you listen to them and you may get like two or three questions right on your test from like the one podcast. And most of them are pretty short. Although I have some big ones that are very high, like the electrolyte podcast.

Yes, it's a it's a lengthy podcast, but it's like super comprehensive, right? And it will help you deal with pretty much any electrolyte situation you'll see on your exam. I have podcasts on genetic diseases, on immunodeficiencies, on bio stats, on things of that nature. So let's just go ahead and jump in. So I'm just giving those as like suggestions. Again, for people that have tutored that I've done really well on the exam, many of them have followed somewhat similar plans. And if don't extremely well, even people that have been recent test stickers. So let's go ahead and go to series five of the November 2020 US Emily step two CK changes, right? So the thing I think I want those to discuss and also discuss that diagnostic errors. That's going to be the main main point of today's of today's a presentation, right? So the thing is so what's a diagnostic error, right? So a diagnostic error can take on many different forms, right? And we'll talk about the common ways people make diagnostic errors and ways to prevent diagnostic errors, right? But essentially, if you don't provide the patient with the correct diagnostic diagnosis, that's a diagnostic error. Or even if you have the correct diagnosis, but you don't provide it to the patient in a timely manner, that's also a diagnostic, that's also a diagnostic error.

Like for example, right, let's say you're radiologist and you read an image, you you find something that is pregnant, let's see, you find like a pulmonary embolus, but then you just put it in your report and you don't call the clinician, right? That's other than study. I mean, that's a diagnostic error because the clinician may not remember to check your read, right? So in that circumstance, you have essentially committed a diagnostic error. And the thing is that diagnostic errors are particularly important. If you look at the field of internal medicine, the most common cause of malpractice claims, especially among people in internal medicine, is actually a diagnostic error, right? And the thing is many times, when people make diagnostic errors, usually make these errors based on cognitive issues, right? So like issues of the brain, right? So like they don't think about things the right way, or the miss out on certain things they should have thought about in the first place, those are all things that ultimately lead to diagnostic errors. In fact, there are some buzzwords that your friends at the MD make expected to understand with regards to these diagnostic errors, right? So like one classic thing they love to throw an exam as a potential cause is something called premature closure, right? So what is premature closure? Again, these specific terms, that's why these exam questions are kind of like weird for people, right?

You need to make sure that you understand what's going on, right? You need to understand some of these buzzwords. If you ever learn about diagnostic errors, they are going to test diagnostic errors with them kind of requiring you to know these buzzwords at the back of your mind, right? So premature closure is basically where you accept a diagnosis and then you like, and I will give examples of all these things, right? So you accept the diagnosis and you're like, okay, you know, they're not going to do any further diagnostic evaluation, right? So see for example, a patient comes in and this patient is an alcoholic, right? This patient is an alcoholic and they are coming in with like very severe gastric pain and vomiting and you're like, of course, this is going to be acute pancreatitis and then based on your, of course, this is going to be acute pancreatitis. You don't do any diagnostic studies, you don't check their lipids, you don't get any labs, but you just bring them into the hospital and start treating them for acute pancreatitis. That's something called premature closure. The problem with premature closure is, yes, the patient may be presenting with what may look like acute pancreatitis, but they may actually end up having something completely different that is just presenting or showing up like acute pancreatitis. You miss out on that diagnosis and then maybe the patient is harmed as a result of that or the patient has less than ideal outcomes.

From your health gaseous result of that. So that's a reason why you don't want to go with just premature closure, right? And the thing is, if a malpractice lawyer sees you did something like that, oh, they will eat you alive, right? They will eat you alive because they know that you did not go along with the standard of care. This is why it's important. Regardless of how many years you've practiced health care, don't lose sight of just common sense and humility because again, you can get in trouble very quickly when you think you know too much. We're like, oh, I've seen this before being there done that and then begin to make all these crazy mistakes. Another buzzword you want to understand is something called a diagnostic momentum, right? Diagnostic momentum. That's another buzzword. So we've talked about premature closure. You want to understand the term diagnostic momentum. So what does diagnostic momentum mean? It's very similar to premature closure, but basically it's where you've considered something super, super early in your process of working up the patient and you keep moving, moving, moving towards that diagnosis you've made. Even if you did it, you're getting does not support it. You don't like almost like stop and think that wait. What's going on here? Right? So like, for example, let's use this same malpractice business, right? So the patient presents alcoholic 3 D history, severe pigastric pain, radiating to the back, nausea vomited.

You're like, oh, this is definitely acupunctitis. But then let's say, you know, you're not a premature closure kind of guy. So you're like, let me go ahead and check the person's lipies. You check the lipies, the lipies is normal. You're like, that's weird. And then you're still treating the patient like acupunctitis. And then let's say you're like, this is going to bizarre. You check the CT, you get a CT, it's going to be a little bit of pelvis. And it's negative acupunctitis. But you keep, you still keep exploring, exploring, exploring, exploring, exploring. You keep pushing, pushing. It's almost like you've started something rolling down the hill and you don't want it to stop anymore. Right? So you keep going, going, going, going, going. Even if the data, like, yes, I know it thought this was acupunctitis. The data that I'm getting from my labs, from my imaging is not agreeing with it. But you keep going, right? You keep the momentum flowing. That's what's known as diagnostic momentum. And then another thing that, another buzz word that they love to throw an exam in relation to these diagnostic errors is something called confirmation bias, confirmation bias. Right? So what happens with confirmation bias? Essentially, you've made a diagnosis, right? You're like, oh, this is the diagnosis I'm going with. And then you keep trying to find ways to prove your diagnosis. You don't try to look at any kind of evidence that disproves your diagnosis.

So you're like, it's almost like, you know, you know what you've diagnosed. So you're just going to keep almost like to slap your ego really well. Like, yes, yes, let me keep doing this, you know, just to support my diagnosis, but you don't ever like stop and think, hmm, or maybe something weird that I'm missing out on here that maybe going on with this patient that I've not considered. So whenever you're practicing medicine, that's why they are bringing in these questions because they see that this is one of the most common causes on medical air in the US. So whenever you're working on a patient, it's always prudence to, yes, try to prove your diagnosis, but also try to consider information that can disprove your diagnosis. That way, you're covering your business. The thing is, in healthcare, especially in my practice, if you consider everything and you document everything, then you are very likely not going to get in trouble if I'm a practice lawyer or if some kind of patient starts coming after you because they analyze the medical records and see that, oh, you're almost proved with beyond reasonable doubt and you also disproved beyond reasonable doubt that something weird was going on with the patient. So these are all examples of things that can happen with with diagnostic errors. Sometimes, you may also see this buzzword where a person has like a 40 application of knowledge.

Basically, you have the, you have knowledge, but you just don't necessarily use it prudently in caring for the patient. So let's say you just miss out on your, like you know about how asthma should be treated. Let's see, you've read about it. But let's say, oh, you know, a person, you're, you're putting them on oral steroids instead of putting them on a lab at first before those oral steroids. And that'll be a 40 application of the knowledge that you have. So again, these are both words you absolutely want to make sure you know in relation to diagnostic errors. Don't forget the premature closure. Don't forget diagnostic momentum. Don't forget confirmation bias. Confirmation bias is essentially the bias that if you really think deeply about this is the bias that is essentially presenting people that have premature closure and diagnostic momentum. And then don't forget this whole issue of the 40 application of knowledge. So now, moving on with this, let's then talk about some techniques. You should use an MBM exams. You should use an MBM exams to prevent diagnostic errors. Right. So the first thing you need to do is you want to have this concept of a heuristic. So it's spelled as H-E-U-R-I-S-T-I-C. You want to have this concept of a heuristic in your mind. And the MBM need to love to routinely test these heuristics. Right. So the first one is something called an availability heuristic.

So basically, I feel like these things are best is give, like, you know, explain when I give examples. Right. So say for example, you've seen something recently. Let's say you had some patient that presented with, again, epigastric being related to the back, nausea, vomiting, and it ended up being a Kid Banker Titus. And then you're like, oh, whenever I see a person that presents like this in the future, it is going to be a Kid Banker Titus. That's an example of an availability heuristic. Right. Or let's say you see a person. Maybe I think that maybe that was not the best example. Let me try another example here. So let's say you see a patient and this patient was an alcoholic. Right. Actually, this is a much better example. So this patient was an alcoholic. This patient had a pigastric pain relating to the back. But then after he did your work up for that patient, actually, ended up being DKA instead of a Kid Banker Titus. And then let's say you see a similar patient in the future alcoholic epigastric pain, relating to the back, nausea, vomiting. And you say, oh, this is DKA. This is DKA. The thing is, yes, you've had a patient that had that similar circumstance in the past. And it was DKA. But you are not really considering the most probable thing in that instance.

That's something called an availability heuristic where you look at something that you've seen recently and then use that as your framework for like any clinical decision that involves a similar presentation that can lead a person down a rabbit hole with regards to making the proper diagnosis. And then another thing that another heuristic that classicy pops up on exams is something called the the anchoring heuristic. Right. So the anchoring heuristic. So the anchoring heuristic basically, you settle on some kind of diagnosis. And even if there is data that just doesn't seem to match, you still keep going down that rabbit hole. Right. So say for example, this whole case of again, a person having a good, a good pancreatide like you see this person with alcoholic nausea, vomiting, a bigotry pain going to the back. I was like, no, I've seen DKA in the past. No, no, no, no, no, I've seen DKA in the past. I've seen DKA. I saw this as DKA in the past. And then let's say you're checking though. And this person's ketones are negative. This person's glucose is not high. But you still keep going, going, going, going, going, going, going, like you don't want to let up. That's an example of the anchoring heuristic. Right. You've settled on a diagnosis early. So it's almost like you're too proud to admit that you were wrong at first. So you just keep going, going, going, going. Even if there's data that does not support that diagnosis.

And then another heuristic, and this is one that many people tend to confuse with the availability is something called the representativeness heuristic. So I think maybe doing a compare and contrast here will be helpful. Well, let me talk about the representativeness heuristic first because I know some of you may be like, no, the vine, this is exactly the same thing as the availability heuristic, but it's not. So say for example, you'll see a person that again, you've worked with a person, you've seen patients in the past that they were alcoholics, they had a bigotry pain, redidine to the back. And they had nausea and vomiting. You're like, oh, this is a acute pancreatitis. You diagnose them correctly in the past with a acute pancreatitis. And then you essentially assume that every alcoholic you see in the future with a pigastric pain, redidine to the back with nausea and vomiting is always going to be a acute pancreatitis. And you don't consider any other thing. That's an example of the representativeness heuristic. So you essentially using pattern recognition. Again, there's nothing wrong with using pattern recognition, but sometimes a pattern may come to you that you've seen before, but it's a completely different disease that is presenting in that patient. Right? So I think one thing that may be helpful here, less differentiate between the availability heuristic and the representativeness heuristic.

The availability heuristic is I'm going to use the same a pigastric pain redidine to the back nausea and vomiting to both trans-both points. Availability heuristic is, oh, in the past, I saw someone that had a pigastric pain redidine to the back that was an alcoholic with nausea and vomiting. And the person was ultimately diagnosed as with having decay. So in the future, you see people that have that same presentation. Are you keep assuming it's decay? Yes, that can be a presentation of decay, but to be honest with you, if you're just going based on what is most common, what is most classic, people that are alcoholics that have a pigastric pain redidine to the back with nausea and vomiting, they likely have acute pancreatitis. So in the availability heuristic, you've seen a common presentation, sharp as an uncommon disease. So whenever you see those common presentations in the future, you always keep considering that on common disease. You don't consider the thing that is the most likely. That's availability heuristic. The representativeness heuristic is a pigastric pain redidine to the back, nausea and vomiting. The person was diagnosed with acute pancreatitis. So everyone you see in the future that presents that way, you're like, oh, it's acute pancreatitis, it's acute pancreatitis. And you never consider any other thing that may be happening, that may be causing that same kind of presentation like decay.

I like using this example because I actually had a somewhat similar experience with my medicine rotations, where there was a person that was diagnosed, like when you had a median patient from the emergency was diagnosed as having acute pancreatitis. But when you considered the information that was presented, like the labs, the imaging, everything, the person looked a lot more decay style than an acute pancreatitis style. And catching that right was helpful in the care of that patient because that's something that could have been missed. And the patient may have had like really, really bad outcomes in the hospital. So it's just one of those good things to keep in mind, right? Don't always approach each patient, almost in an undifferentiated format. I'm not saying you shouldn't consider the most common things you should, but you should also just at least spend the sliver of time considering other things that may cause a similar presentation. That's why it's usually good to construct a differential diagnosis. Okay, so let's keep going. So that's one way to deal with diagnostic errors. Just understanding this whole concept of heuristics. And again, we've talked about the availability heuristic. We've talked about the anchoring heuristic. And we've talked about the representativeness heuristic. Now, another thing that is helpful on in-bimbing exams in dealing with diagnostic errors is just using this whole concept of a diagnostic timeout.

So what in the world, when you're in a diagnostic timeout, basically what I mean is, when you're caring for a patient, just always, even if you've made a diagnosis, even if you study treatment, just periodically sit down and just consider the facts of the case. Again, this is a diagnostic, this is actually a method of preventing diagnostic error that's very useful if you're an ICU physician or you're working with very complex patients. Just every now and then, even if it's once every day or once every two days, and this will be especially useful for those that, you know, I assume many of the police into the spotcas are going to be residents at some point in the future. Just sit down and think like, okay, let me just consider everything. Let me just use a fresh set of eyes. It's almost like you're considering cold cases. Yes, it's not a cold case, but just fresh set of eyes. There are things, especially when you notice that a patient is being treated, but you don't seem to be getting better like you expect them to get better. Then you should begin to take these diagnostic timeouts. So you just sit down and just think and consider. I remember there was a senior I worked with during my intern year that really had this mantra of like, let's just sit down and think about this patient again.

And many times, we'll catch things that are very valuable for patient care or that turn the patient's care around in the hospital from having that kind of thought process with with caring for patients. So I think that's a good thing to do. That's the whole concept again of a diagnostic timeout. And then a third strategy is just admitting your mistakes, right? So again, you're not perfect, right? This is the kind of thing that happens with those premature closure people and all that stuff. If you've made a diagnosis and you ended up being flat out wrong because the thing is in medicine, right? Many of us have very big egos for good reason. Many of them, I mean, they should never be a good reason to have big egos. I take that back. But many people in medicine, they are type-up personalities. They've been the best in high school, best in college. They have like perfect as in many things. So it's really hard to get these people to admit to their mistakes. But again, admitting to your mistakes, that's the first step in redemption, in going towards the right path. Because again, ultimately, you only take good care of the patient, right? You don't want to take good care of your ego. So that's just something that I think you should keep in mind as you're going through these things. And then another thing that also helps with reducing diagnostic errors is doing this thing called was key scenario medicine, right?

So practicing this thing that many people call was key scenario medicine. So the thing is, when you're caring for a patient, and this is something that is employed a lot in the field of emergency medicine, just always ask yourself, what is the most life-threatening thing that may be causing this presentation? Consider that a, consider that first, roll that out first. It basically prevents you from having to, from missing things that may be particularly important to me, kill the patient quickly. If they're not identified or quickly untreated. I'm not saying, oh, because you are considering the most life-threatening diagnosis, you always need to test for them. No, you don't always have to test for them. We should at least consider them. In fact, many times to protect yourself from a medical legal perspective, documenting your chart that you consider this, but you consider it to be less likely because of XYZ. That's always a prudent thing to do. Again, unfortunately, with a medical system in this country, you need to document to also protect yourself from lawsuits essentially. And then another thing, this is probably my personal favorite in terms of reducing diagnostic errors, but again, it's something you could see on your exam, is being systematic in approaching common problems, right? Have an approach to XYZ, have an approach to ABC, right? So for example, that is one thing that helped me in my internship was just being very systematic.

Being very systematic in solving problems, being very systematic, like I had a process that I used in admitting patients. I had a process that I used in writing discharge summaries. I had a process that I used in writing my assessment and plans. I had a process that I used in rounding up on patients. So the thing is, by having a process for everything, you can, it's almost like you have like an algorithm, it's almost like you have a mental checklist that you go through. When you have a checklist that is thorough, and you use it regularly, over time, you become more efficient with that checklist, and you are more likely to be successful in that activity that you're plunging into. So being very systematic, right? Like, for example, we use checklist a lot in healthcare, especially like in the field of anesthesia, right? By using all these checklists, you prevent yourself from making errors or missing out on big things because you're essentially creating like a standardized process to solve in a problem, right? And it felt like even in terms of like in the testic and strategies course, I teach, I teach people standardized approaches. So the people I tutor one on one, I try to, oh, okay, let's say I'm meeting the 2 T for the first time and I see that, okay? They failed an exam, they performed poorly on exams. I look at the kinds of questions they get wrong. I'm like, okay, based on these questions, you've gotten wrong. These are the problems you have.

Okay, let's make an algorithm that you should use for your specific circumstance so that you stop making these kinds of errors. And usually when people start following those standardized processes, they start doing well on exams, right? Like one thing that buffles me about people taking the USML exams is you see these people, they're taking these exams, but the approach questions will be nearly, the approach questions like, oh, this question, they do this, this question, they spend three minutes here, this question, they spend 30 seconds, this question, they do this, this question, they do that. They don't have any formalized standardized approach to take to practicing, to walking through problem sets. That's usually not a good thing for your exam score. You want to be as standardized as possible in the way you take exams because when you're standardized, even if the exam, you essentially boiling your exam down to you, did you follow principles as against, or was the exam hard or easy or whatever. Regardless of the difficulty of an exam, if you have the same consistent approach, chances are you will get the same consistent results after a reset and done. And then another way to reduce the agnostic errors is to ask why, ask why, ask why, right? So always, this is the thing like it's almost like pathophysiology based thinking. So whenever you see a patient presenting a certain way, just ask yourself, what may have caused this, right? What may have caused this?

This is actually a means of being hardworking in the way you think, because many people believe it or not are very lazy in the way they think. So they see something, they see a smoker, the smoker comes in, you know, a smoke two packs of cigarettes every day for the past 40 years, present comes in with shortness of breath, comes in with like productive cough and all that stuff. You're like, Ben, COPD exacerbation, yes, this is COPD exacerbation. But you should always not just stop at, oh, it's a COPD exacerbation. Challenge yourself to ask yourself, okay, what was the thing that changed? That prompted this person to present with a COPD exacerbation. Like what is the thing that the person get an infection, that the person have pneumonia, is the person having the person have some kind of environmental exposure or something? The thing is when you always try to ask yourself why, you typically get to the root of a person's problem and you'll be more refined in the way you treat or test for those clinical problems. But if you have the kind of person that has no pathophysiological understanding, which, you know, sadly, affect some healthcare workers. Again, I'm not going to mention a specific discipline or specific field within healthcare. But there are absolutely individuals in healthcare that don't have the same level of training. They don't have, basically, they don't have the commensurate amount of training to be doing their jobs.

So all they know to do is just to recognize things as they present. But they are never able to think through, what is the thing that's actually causing this presentation? Right? And because they don't have that pathophysiological understanding of why is this thing presenting? Like why does this person have the COPD exacerbation? Why does this person have the CHF exacerbation? These people just order every test known to man. Order order order every test known to man. Drive up the cost of healthcare. And the many times things that are very important get missed. I mean, these are things I've seen so many times. I mean, I remember like in the ICU have absolutely seen people make very similar errors. But these are people that they don't have the level of training that is requisite to seek clinical problems, to seek clinical presentations and not just put labels on them, but understand the reasoning behind those labels. Right? Those people, the you know, drive up the cost of healthcare, make a lot of errors. I feel like many of you listening to those podcasts know exactly what I'm talking about. But again, I need to be mindful of people, right? So that's why, but I think we all understand this. But I'm just saying this, even if you're in that situation, try to understand why. What is the why? Don't just is just like learning things and you're studying for USML exam.

And all you do is you're just focused on Oh, this fact, this fact, this fact, this fact, this fact, that's one of my problems with Anki, like if people make Anki cards, they memorize all these details. But then you try to get them like, okay, so why is this? So what's the why? What's the understanding behind this concept? Like, oh, why does why does why does caught compression cause a variable D cell? Right? If you're like, oh, caught compression variable D cell, caught compression variable D cell. Yes, any human being can memorize that. But do you know why a caught compression causes a variable D cell? The thing is if you understand the why, you won't have to memorize as much, right? Many people think that, oh, divine, the guy that makes these podcasts rule, this, this, this kid has excellent memory. Well, thankfully, I have great memory, right? But many of the things that I teach people is not some stuff that I just ooh, magically memorized is something that I understood and based on that understanding, you don't really need to memorize because there's just like an organized schema in your mind for how to approach that problem. Like, the trilogy of follow, for example, the trilogy of follow is something where is perfect Anki material for many people. But do I ever need to memorize the findings into the trilogy of follow? No, because there is pathophysiology behind it. Or when you see people, they get questions about like billions of them in like in a neonate. You see them?

They start, oh, okay, I have this list of things I've memorized on my differential. But you don't understand the reasoning behind all these things. Like why? Because many times, if you have the why understanding, one again, you'll be able to figure out, oh, you know, this is exactly what is going on with this patient. So you may, instead of ordering 10 different tests, you may just order one test, like one best test, one on usual test and figure out exactly what you need, right? Versus ordering 10 tests. So that why reasoning is something that is particularly helpful, especially when you're studying out as a clinician, they say you're like an intern, your first year resident trying to understand, okay, why does my patient have this? Why does my patient have that? Don't just accept things, try to explain why. Especially when you're doing a nice year rotation, I'm telling you this method of thinking makes a huge, huge, huge difference. But I guess since I'm talking about this podcast, this is more for purposes. Again, these podcasts are no meat for clinical decision-making. I feel like I need to mention that again from a legal perspective. But again, this is just something that I've used quite extensively in my career as a physician. And it has absolutely, absolutely, absolutely helped me. So again, just, just things to keep, keep in mind.

And then another thing that is also helpful on MDM exams in terms of reducing diagnostic errors is employing something known as base theory, employing something known as base theory. Base theory is spelled B-A-Y-E-S. When you employ base theory in the right way, it would help you make outstanding clinical decisions. So you may be like divine, are you about to inject like a lot of bio-stats into my veins or something? No, I'm not trying to inject bio-stats into your veins. Essentially, what I'm going to be talking about here is whenever you're doing a test on a patient, always try to consider two things. First, this is basically like the five-year-old guide to base theory. First, ask yourself, where does this patient fall in terms of the risk? Would you consider this patient to be a low risk person for this problem or intermediate risk person for this problem or a higher risk person for this problem? And then the second thing should consider are testing probabilities. So what is the pre-test probability of this particular diagnostic test I'm selected? What is the post-test probability of this particular diagnostic test so let me give you an example here. So let's say a patient comes in, all right? And I will give you two examples of patients. So you have a patient comes in. This patient is a 23-year-old, so an athlete, MBA player, six foot eight, weighs like 180 pounds. So this person's BMI is amazing.

This person doesn't smoke, this person doesn't consume alcohol, this person doesn't eat sugary foods. This person is on a plant-based diet, it salads like all the ones you. And then they come in with like some, you know, some shortness or breath, chest pain. If you order a D-dimer in those people and it comes back high, yes, you're worried about a PE, but you're like, yes, wow, okay, this person's D-dimer is high. Like you selected that D-dimer in the first place for good reason because you're like, hmm, this athlete, this person is super healthy, this person should not and this person did not have any car rides, nothing, right? So it's like you've considered all these pre-test probabilities before you even selected your diagnostic test. That's that's that's that's pretty thinking by using base theorem. So many people intrinsically use base theorem but they just don't realize it. So you consider that this person is low risk, so I'm not going to jump straight to a CT and yoga. I'm going to do a D-dimer test. In fact, to be honest with you, this is why again, many times I tell people, don't just memorize the agnostic algorithms, try to ask yourself, what is the why? I'm telling you this, many diagnostic algorithms, if you really sit with them and think about them, you'll see that many of them actually have magical bases for, or this is why we divert towards this step here, this is why we divert towards this step here.

Many of those things, you can reason them out with base theorem, right? It's almost like you're able to predict, this is the next thing we should do, even if you don't necessarily know the algorithm, this is the thing that makes logical sense based on this patient's pre-test and post-test probabilities, right? But if for example, a different patient is like a 37-year-old female, she smokes two packs of cigarettes every day, she's on OC Ps, she, she just took a long flight from from New York to Alaska or something like that. Then obviously that patient ordering a D-dimer in that patient is not prudent because if that D-dimer comes back negative, comes back normal, and you're like, oh, the D-dimer is negative in this person, and you're like, oh, you know, because of we don't need to test this person any further, guess what? You're going to make a big diagnostic error, right? Because that patient was not the same level as risk as the athletes that I talked about in the first case. So in this kind of patient, using a D-dimer is not prudent, it makes sense to just go straight to something that can give you a definitive diagnosis, like a CT and geogram of the chest, right? So that's an example, these are, that's like a good example of base theorem, using base theorem, considering the risk in the patient and the pre- and post-test probabilities, will help you be again, a lot more refined in making the right diagnosis, making the right diagnosis.

And then if for example, another thing that you can use on NV Me exams to reduce diagnostic errors is to just ask yourself, are there some things in this patient's presentation that does not fit the diagnosis that I'm trying to make, right? So for example, if a person presents again with, you know, epigastric being redid into the back nausea vomitting alcoholic, or no, let me use a different example. So epigastric being redid into the back nausea vomitting, but a person is not an alcoholic and the person does not have hypercalcemia or the person does not have hyperglyceridemia. You should begin to potentially consider the things besides acute pancreatitis that's causing the patient's presentation. Again, don't just chalk it up to, oh, it's idiopathic, no, no, no, no, no, no, no, I know many of us take that pop out, right? Idiopathic, idiopathic, idiopathic. But again, that can cause you to miss some things that could potentially be life threatening, life threatening for a patient, right? So again, sometimes consider zebras, okay? Sometimes consider zebras. And nothing that, oh, you should have zebra be thinking for everything, everything should be done in moderation, even that's what the Bible says, right? But just again, consider, consider zebras, don't just completely chalk them off and then running to run into a diagnostic era. So these are the main things on in-bim exams that you should do with diagnostic errors.

One thing I want to say though, because the in-bim can bring this up as a systems-based factor that makes people more prone to committing diagnostic errors is this pressure of performance, right? So pressure of performance, pressure of performance you can arise in one of two ways. Like for example, one classically you can think about this is with like press guinea in emergency rooms where you just have to crank through so many patients in a short period of time and get them in and out, get them in and out. Whenever you are in that circumstance where you have so much work on your pleats, you have so many pressures to perform, the chances are you will not be very thorough in working on your patient. What you will likely try to do is just, okay, let me just order every test, see like throw many dark, see whichever one sticks and then go from there, right? Ultimately that is not high value care at all. Yes, you know, maybe you're making the diagnosis by ordering all those tests, but at the end of the day, you're essentially driving up the cost of care, right? You're driving up the cost of care. So all those pressures that have been placed on clinicians to do this, do that, do this, do that, basically do more and more and more and more and more and more with less and less and less and less and less, right? I'm not saying you shouldn't try to do more with less, but again, there's a place where the rubber meets the road.

There should be a good happy medium where you're also not just almost like running your patients through an assembly line, right? So again, that's a systems factor that can absolutely, absolutely, absolutely increase the presence risk of diagnostic errors. So I think I'm going to go ahead and pause here. So again, this is series five and again, if you're interested in the USM list, the two CK courses that are holding next week, feel free to ship me an email through the website. There's a contact, whatever thing on the website. So the courses are from the 10th to the 12th of December and on the 10th is where we have the testing in strategies class from 2 to 4 30 PM mountain standard time. And then on Friday and Saturday, we have five hours on both days, right? So five hours. So basically 11 a.m. to 4 p.m. mountain time on the 11th of December and 11 a.m. to 4 p.m. mountains standard time on the 12th of December. So if you're interested in any of those courses, that's the comprehensive 10-hour step to CK course. Feel free to reach out to me and I'll be more than happy to give you some more information on pricing and things of that nature. So thank you for listening to this podcast. I will see you in the next podcast. God bless you. Have a wonderful day. Thank you.

Failing to provide the correct diagnosis, or failing to communicate the correct diagnosis to the patient in a timely manner.

Premature closure, Diagnostic momentum, and Confirmation bias.

Accepting an initial working diagnosis without performing necessary further diagnostic evaluation or studies.

Confirmation bias is actively seeking evidence to support a hypothesis; Diagnostic momentum is continuing to pursue a diagnosis even when new data contradicts it, like rolling down a hill.

Pathophysiological understanding, which allows the clinician to reason through the underlying cause rather than just labeling symptoms.

To systematically consider and weigh the patient’s pre-test probability (risk) against the diagnostic test results (pre-test and post-test probabilities).

Premature closure.

Representativeness heuristic.

Diagnostic timeout.

Continuing to pursue a diagnosis despite accumulating evidence that contradicts it.

Always considering the most life-threatening potential cause first (Worst Life-Threatening).

Consideration of both the patient’s pre-test probability (risk) and the test's post-test probability.

Premature closure.

Representativeness heuristic.

Diagnostic timeout.

Continuing to pursue a diagnosis despite accumulating evidence that contradicts it.

Always considering the most life-threatening potential cause first (Worst Life-Threatening).

Consideration of both the patient’s pre-test probability (risk) and the test's post-test probability.