#126 Kashlak Morning Report with Human Dx

November 19, 2018 | By Matthew Watto, MD

Practice solving diagnostic puzzles at Kashlak Morning Report with Internist / Diagnostician, Reza Manesh MD, Assistant Program Director for Clinical Reasoning of the Osler Medical Training Program at Johns Hopkins! Solve along with us at these links: Case 1 and Case 2. Topics include: clinical reasoning terminology, how to use cases to practice diagnostic reasoning, how to build a diagnostic schema, and how to conduct your own cognitive autopsy.

Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Credits

Written and Produced by: Hannah Abrams

Hosts: Hannah Abrams, Paul Williams MD, Stuart Brigham MD, Matthew Watto MD

Guest: Reza Manesh MD

Special thanks to: Doctors Steph Sherman, Zaven Sargsyan, Anand Jagannath, John Inou Hwang, and Rabih Geha for contributing cases

Clinical Reasoning Pearls

1. Diagnostic reasoning is a skill like any other. If you dedicate the time to deliberately training your brain well, you can develop your skills, too!
2. Devoting an hour to developing a diagnostic schema (a systematic approach to a clinical problem e.g. hypoglycemia) builds your knowledge, enhances diagnostic skills, and improves learner retention. Practice and refine your schemas as you see more cases!
3. What’s a ‘cognitive autopsy’? It’s a method of reviewing your own diagnostic reasoning and finding ways to improve the next time you face a diagnostic dilemma. Look below for some example questions to ask yourself!  
4. Never be afraid to put a few terms into Google if you’re stuck!

Kashlak Morning Report Show Notes

Human Dx & Global Morning Report

Human Dx

“Human Dx” or “the Project” is a worldwide effort created with and led by the global medical community to build an open intelligence system that maps the steps to helping any patient. Their idea is that by combining the collective intelligence of doctors with machine learning, they can enable more accurate, affordable, and accessible care for all.

Global Morning Report

Human Dx chooses three cases per day (Adult Medicine, Pediatrics, Primary Care) to serve as Global Morning Report. The cases are reviewed by at least two editors, teaching points are added, and they are distributed via email to registered users and via the Human Dx app. Listeners can get CME credit for solving the cases!

Format

Like in a real patient case, a limited amount of information is provided from which you create your working differential diagnosis. As you get more history, exam findings, or tests, you can update that differential until you get enough information to reach the actual diagnosis. After, you can see how others solved the case and how you did on:

1. Efficiency: How much information you needed to reach the right diagnosis
2. Accuracy: Whether you’re correct or incorrect, and how high the actual diagnosis was on your final differential before you submitted

Open Access Publications

You can submit cases to gmr-admin@humandx.org and the GMR editors will review the submissions. If published, you can cite it on your CV as an open access publication.

Kashlak Morning Report – Episode Format

On this episode, we’ll present 2 cases: one for Reza to solve and the other for the Curbsiders team. They’ll attempt to solve it in real-time without any prior knowledge of its content, and with each new diagnostic finding we’ll figure out what our differential diagnosis is and what we think is most likely going on. At the end of each case we’ll reveal the diagnosis, talk through a few teaching points, and do a “cognitive autopsy” of our own diagnostic reasoning process. To play along, follow these links: Case 1 and Case 2.

Clinical Reasoning Terms

Check out https://clinicalreasoning.org

Problem Representation

Highlighting the defining features of a case, including epidemiology, duration of symptoms, and clinical syndrome. “This is what you enter into the Google Chrome search engine.”

Illness Script

Your mental ‘file’ for a disease process, including pathophysiology, clinical syndrome, diagnosis, treatment, and epidemiology.

Cognitive Autopsy

Reflecting on your own diagnostic thought process and seeing if you could have performed better or not; assessing your mistakes to see if you could have performed differently if presented the same clinical scenario again.

Iterative Hypothesis Testing

Coming up with a hypothesis, and then testing it and either accepting, rejecting, or modifying it. This is what Human Dx prompts you to do!

Diagnostic Schema

A systematic way to tackle a clinical problem by having an organized approach.

Case 1 & Building a Diagnostic Schema

About Case 1: Written by Dr. Zaven Sargsyan and edited by Dr. Stephanie Sherman, the case of a “44-year-old woman with recurrent episodes of dizziness and palpitations.”

Building a Diagnostic Schema

Diagnostic schemas are a helpful tool to build for a given syndrome or symptom. They can also serve as ‘checklists’ for diagnostic workups to make sure you don’t miss anything!

1. Set out a block of 30-60 minutes to think about how you want to conceptualize the causes of a symptom.
2. Look at clinical sources, like UpToDate or NEJM, to build a framework e.g. Try looking at the NEJM clinical problem solving series to borrow ideas from experts!
3. Practice teaching your schema to residents and medical students
4. Evolve your schema over time as you see more cases!

Case 2 & Conducting a Cognitive Autopsy

About Case 2: Written by Dr. John Hwang, the case of a “63 year old male presenting to the clinic with jaundice.”

Cognitive Autopsy Starter Kit Questions

1. What were your initial cognitive biases about the case?
2. Did your initial ddx include the final dx?
3. What was your ‘gestalt’? Was it right?
4. What aspects of the case led you toward one diagnostic category or another as you learned more
5. Were there any points at which you wish you’d paused and rethought your framing?

Goals and Learning Objectives

Goal

Listeners will learn to use case-based exercises to ‘train their brain’ and improve their diagnostic reasoning.

Learning objectives

After listening to this episode listeners will…

1. Be familiar with the basic clinical reasoning terminology
2. Develop a framework for case-based practice of diagnostic reasoning
3. Practice clinical reasoning
4. Learn to conduct a cognitive autopsy of their own diagnostic reasoning process

Disclosures

Dr. Manesh recieves an honorarium from The Human Diagnosis Project for his role as supervising editor of the adult medicine section of Global Morning Report. The Curbsiders are an educational partner of The Human Diagnosis Project for this episode.

Time Stamps

• 00:00 Disclaimer, intro and guest bio
• 04:02 Guest one liner, book recommendation, favorite failure, advice for learners
• 11:27 Human Dx Project and Global Morning Report
• 15:35 Diagnostic terminology
• 21:25 Case #1, Reza solves
• 33:40 Diagnostic autopsy and teaching points for case #1
• 38:00 Case #2, The Curbsiders solve
• 57:30 Diagnostic autopsy and teaching points for case #2
• 61:33 Take home points and a plug
• 64:30 Outro

Links

Links from the show are included above.

1. The Book of Joy: Lasting Happiness in a Changing World
2. Core IM Podcast: Hoofbeats Part 1: 85F with Acute AMS
3. Clinicalreasoning.org
4. IgG4-related disease. Lancet, April 2015.
5. An Inquiry Into the Early Careers of Master Clinicians. Journal of Graduate Medical Education, October 2018

Citation for guest CV

Manesh, Reza. Guest expert. “#126: Kashlak Morning Report with Human Dx.” The Curbsiders Internal Medicine Podcast http://thecurbsiders.com. November 19, 2018. http://thecurbsiders.libsyn.com/126-kashlak-morning-report-with-human-dx-0