"How Doctors Think" and my two lists

[tum]

I recently finished Groopman's book (yes, I admit it) and I have to be frank--it got me thinking alot about how I think. And in many ways it reminded me of why I got into this game in the first place.. there's a great section in the book about a priori knowledge (http://en.wikipedia.org/wiki/How_Doctors_Think#The_fallacy_of_logic) which I've seen exercised countless times on these forums and definitely on more than one occasion in the hospital.

in any case, there's an israeli-brazilian gastroenterologist at MGH, as groopman admits, is a bit quirky. the flip side of this is he's warm, engaging, and brilliant.

groopman talked about him doing something that i thought was very eloquent and humble. he made 'two lists'.

the first list was of mistakes he had made during his training and practice. he looked for things they had in common, as well as times he had been fooled by a 'bread and butter' diagnosis. and he started to see patterns in his thought process that either he needed to be aware of.

the second list was a little trickier. it was of things he had done where he had caught a difficult diagnosis or dealt with a tricky situation well. he wanted to try and pinpoint the subtle process involved with being 'in the zone'.

i know there are case reports and m&m's for precisely this reason. but i thought it would be interesting if any brave posters would like to try and make a list of the moments that they slipped up. i'll go first:

- once i admitted a patient who i admitted who had woken up that morning with severe back pain, had non-bloody emesis, passed 'blood' in his urine and passed out. ended up having a huge triple AAA that had hemorrhaged into his kidney, causing him to pass blood. kept waiting for the stone and no stone showed up

- with psych patients, i need to be very aware of medical (especially rheum) conditions that can overlap. had a guy come in schizo-a that had exacerbated, ended up being overlying MCTD/Lupus

i'm too annoyed by admitting these two to continue for today : / i think my main problem is expecting bread and butter too quickly then being suprised when nachos hit me in the face.

looking forward to your lists.

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[pillowhead]

- with psych patients, i need to be very aware of medical (especially rheum) conditions that can overlap. had a guy come in schizo-a that had exacerbated, ended up being overlying MCTD/Lupus

That reminds me of an interesting patient I had on my neurology rotation. He came in paralyzed from the waist down but he also was very bizarre--full of neologisms, word salad, delusional, auditory hallucinations, etc. His MRI was classic for multiple sclerosis and the guy was a young man with no past medical history that we knew of. Neuro team felt his behavior was due to the multiple sclerosis.

Then psych sees him. Turns out he is well known to them and had given us a fake name. Apparently he was a schizophrenic patient who had also happened to develop multiple sclerosis. It was interesting because I feel more often than not, you'll have more success if you look for one disease process causing multiple symptoms. But as always, patients can have just as many diagnoses as they darn well please which was the case with this man.

 

[sdnetrocks]

"A man can have as many diseases as he damn well pleases"

 

[tum]

Or as Dr. Lewis told Groopman, if you're not sure what the hell is going on, "don't just do something, stand there".

Or 'in a code, the first pulse to take is yours.' (gratis de samuel shem)

thank god we had a generation of hippies go through residency before us--otherwise we would have none of these brilliant little ironies to pass back and forth on rounds.

i guess no one wants to fess up a list. ah well, i'm still doing it in microsoft word.

 

[Mumpu]

Hindsight is 20/20. Many M&Ms end with the consensus that the patient eventually declared themselves and that the initial management was wholly appropriate for the presentation.

Or you can be an ER doctor and CTPE everything that walks through the door. I can name half a dozen patients who are on dialysis thanks to the ER. None of them had PE. None of them had high Wells scores. All clearly had different etiologies for their chest pain.

p.s. The guy with (presumably) the first presentation of nephrolithiasis should've gotten a CT-KUB and it would've shown the aneurysm.

 

[gutonc]

i think my main problem is expecting bread and butter too quickly then being suprised when nachos hit me in the face.

Ah yes, early closure. It's easily my biggest flaw as a clinician and something I've been working hard on the 2nd half of the year. I've been fortunate enough not to have many of them go too far south but I've definitely been embarassed comparing my early notes to the d/c summary:

"Impression: Recurrent lower GI bleed, likely 2/2 diverticuli, consider surgical consult."


" Final Diagnosis: Von-Hipple Landau Syndrome."

Good times.

 

[edinOH]

Hindsight is 20/20. Many M&Ms end with the consensus that the patient eventually declared themselves and that the initial management was wholly appropriate for the presentation.

Or you can be an ER doctor and CTPE everything that walks through the door. I can name half a dozen patients who are on dialysis thanks to the ER. None of them had PE. None of them had high Wells scores. All clearly had different etiologies for their chest pain.

p.s. The guy with (presumably) the first presentation of nephrolithiasis should've gotten a CT-KUB and it would've shown the aneurysm.

Half dozen? Sure.

Come on down to the ER and try it out for a shift if you think you can do better. Otherwise, STFU.

 

[Apollyon]

Half dozen? Sure.

Come on down to the ER and try it out for a shift if you think you can do better. Otherwise, STFU.

This is not new ground with that poster. That poster LOVES to MF EM and EM docs - I believe he's still an intern (or maybe IM 2nd year), but, apparently, is smarter, more suave, technically superior, and just an all around better person than anyone who has ever seen a patient in the ED. Just ask him (or don't - he'll tell you anyhow).

It's funny (in the "not funny" way) that the radiologists would CT someone with the tendency towards renal failure (if it's "half a dozen") without checking the creatinine. I mean, if the patients' kidneys box, it's on the Rads guys' shoulders, at least in part, and 6 times is a pattern. In other words, "Half dozen? Sure." Sounds a little contrived/BS.

 

[tum]

p.s. The guy with (presumably) the first presentation of nephrolithiasis should've gotten a CT-KUB and it would've shown the aneurysm.

Yes, that is how we picked it up. We were lucky to have a strong radiology resident that night.

While I'm not in radiology, my understanding is that timing is crucial to everything. That is to say, if someone is having chest pain and you write "R/O PE", or if they're having back pain and you say "R/O kidney stones" (as opposed to 'chest pain' and 'back pain'), then dye may not be used (in the latter), and even if it is used in the former, the images the radiologist looks at are taken, not as the dye traverses the aorta, but while it is in the pulmonary vasculature.

So yes, while I have heard medical students, residents and even weaker attendings say "the CT was negative, we're ok" with a highly suggestive clinical picture, I would take radiology with a grain of salt in those situations.

By the way mumpu, I know this isn't at all what you were implying. I was just using your remark to make a point. I think you might have made the same point a different way.

In my program, there is no actual ER--the medicine/surgery/psych residents all rotate through with a relatively static attending staff. It is definitely a different mindset. For the most part, I think people trained specifically in ER do it better than we do.

Of course, I'm not saying I haven't come across *****ic admits at other places, but I think it was more of a problem with the arbitration process at those hospitals, not really the ER resident, who was trying to cover his ass, or me, who was trying to sleep. This probably had something to do with our 'different mindsets' as well.

Of course, I'm still quite early in my training, so maybe I'm just full of crap. Would love to see if my very wise SDN peers concur--especially if any radiology folk happen to come across this.

 

[tum]

Oh here's another add on to my list:

-when I was a third year med student (yes, like all of you, I remember most of my stupidities with great clarity), I gave a woman a prescription for an anti-hypertensive. I forgot to tell her to stop the old hypertensive. Not gonna say what happened, but I felt like one giant douchebag that day.

I think my main mistakes come in three main flavors:

1. I'm not systematic enough. I try to hotshot my way past a case to save some time, and not being compulsive and methodical about my algorithms comes back to haunt me.

2. I overcorrect and become too attached to an algorithm, and forget to use common sense.

3. I get too worried about the worst case scenario, and overtreat, creating a new worst case scenario.

Wow, everytime I do this I feel like a real crappy doctor. Maybe this isn't the fun exercise I thought it would be. And am I setting myself up for a lawsuit? Maybe there's a reason M&Ms aren't open to the public..

 

[docB]

Hindsight is 20/20. Many M&Ms end with the consensus that the patient eventually declared themselves and that the initial management was wholly appropriate for the presentation.

Or you can be an ER doctor and CTPE everything that walks through the door. I can name half a dozen patients who are on dialysis thanks to the ER. None of them had PE. None of them had high Wells scores. All clearly had different etiologies for their chest pain.

p.s. The guy with (presumably) the first presentation of nephrolithiasis should've gotten a CT-KUB and it would've shown the aneurysm.

Meh. You show me 6 patients with boxed kidneys and I'll show you a whole medical staff of internists and cardiologists who won't admit a chest pain without a CT because they might wind up with a PE that could have been turfed to another service.

If you hear someone laughing out loud that's the internist who I just told that we don't need a CT because the Wells score is normal.

 

[gutonc]

I think my main mistakes come in three main flavors:

1. I'm not systematic enough. I try to hotshot my way past a case to save some time, and not being compulsive and methodical about my algorithms comes back to haunt me.

2. I overcorrect and become too attached to an algorithm, and forget to use common sense.

3. I get too worried about the worst case scenario, and overtreat, creating a new worst case scenario.

Dude...are you actually channeling me here? For better or worse, #3 is not a huge problem for me, but 1 and 2 are pretty much how I roll. Recognizing it is the best first step though. Now just to see if we can do anything about it.

 

[tum]

If you hear someone laughing out loud that's the internist who I just told that we don't need a CT because the Wells score is normal.

docb, not to defend your internist, but isn't the wells invalid without a quant d-dimer?

as in, i thought people frowned on using the wells because the time for a CT done & read is less than the time it takes for a quantitative d-dimer.

i don't think the internist you spoke with had that same mindset though. likely was just cya. or a 'my attending will bitch if i even think about bringing up the wells score on rounds' kind of thought process

 

[tum]

Dude...are you actually channeling me here? For better or worse, #3 is not a huge problem for me, but 1 and 2 are pretty much how I roll. Recognizing it is the best first step though. Now just to see if we can do anything about it.

no #3? ah, just wait for your unecessarily iatrogenic day to come.

 

[gutonc]

no #3? ah, just wait for your unecessarily iatrogenic day to come.

I didn't say no #3, just way less of it than 1 and 2.

 

[Mumpu]

Mark my words next time you CTPE an 80-year old with a "normal" creatinine of 0.8 (they do teach you about GFR in emergency medicine, right? what about means of preventing contrast nephropathy such as NAC, IVF, and maybe bicarb? I have NEVER seen an ER physician use any of these unless the creatinine was obviously elevated... 0.8 in an old person can mean a GFR of 30 and a 1 in 3 chance of contrast nephropathy). And uh, I did rotate through the ER and it was actually a positive experience. Most ER physicians are not ******s, I think they are just not taught to appreciate the nuances of patient care.

 

[docB]

Mark my words...

Ya know, I was going to respond to this but it's really a total thread hijacker. So, I say to you, "Duly noted!" Now back to the two lists thread.

 

[amrain01]

docb, not to defend your internist, but isn't the wells invalid without a quant d-dimer?

as in, i thought people frowned on using the wells because the time for a CT done & read is less than the time it takes for a quantitative d-dimer.

i don't think the internist you spoke with had that same mindset though. likely was just cya. or a 'my attending will bitch if i even think about bringing up the wells score on rounds' kind of thought process

Wells criteria is still EXTREMELY valid without a quant d-dimer. Medical decision making comes before that- low prob/low suspicion/other diagnosis less likely, then Wells or d-dimer. If you always ran to d-dimer then Wells, you'd end up CT'ing many people for false positive d-dimers with low wells scores.

 

[LukeWhite]

Wells criteria is still EXTREMELY valid without a quant d-dimer. Medical decision making comes before that- low prob/low suspicion/other diagnosis less likely, then Wells or d-dimer. If you always ran to d-dimer then Wells, you'd end up CT'ing many people for false positive d-dimers with low wells scores.

I'm not sure I'd go so far as to say extremely...For DVTs, Wells without d-dimer is about 75% sensitive with a negative predictive value (what I'd say we're after if we want to avoid running the ddimer and the subsequent CT) of 90%. The negative likelihood ratio is 0.46, which means that the patient's half as likely to have a DVT with negative Wells criteria. Not too reassuring.

I'm not sure I know any ER docs who would be ok with these odds when they can run a d-dimer and get a 99% sensitivity.

 

[elizabeth5863]

During my ER rotation, there was a male patient in his 40's with a chief complaint of flu-like symptoms for one week - cough, rhinorrhea, body aches, fever, and headache. When presenting to my attending, I thought it was viral process that would resolve on its own and recommended symptomatic treatment. However, my attending said that he needed to teach me "the fear of God." I didn't think any tests needed to be ordered, but the attending ordered influenza A and B which returned negative. We couldn't find a reason for his symptoms but, given his HA and fever, we did an LP. Results suggested viral mengingitis. The thing is.. the patient didn't really have much of a stiff neck. However his headache was one of his biggest complaints (among others) and his fever was persistent. This is one case that stuck out in my experiences. I guess I missed it because the pt was complaining of multiple flu-like symptoms and I forgot to ask which symptom was bothering him the most. Got lots of more learning to do.

 

[southerndoc]

During my ER rotation, there was a male patient in his 40's with a chief complaint of flu-like symptoms for one week - cough, rhinorrhea, body aches, fever, and headache. When presenting to my attending, I thought it was viral process that would resolve on its own and recommended symptomatic treatment. However, my attending said that he needed to teach me "the fear of God." I didn't think any tests needed to be ordered, but the attending ordered influenza A and B which returned negative. We couldn't find a reason for his symptoms but, given his HA and fever, we did an LP. Results suggested viral mengingitis. The thing is.. the patient didn't really have much of a stiff neck. However his headache was one of his biggest complaints (among others) and his fever was persistent. This is one case that stuck out in my experiences. I guess I missed it because the pt was complaining of multiple flu-like symptoms and I forgot to ask which symptom was bothering him the most. Got lots of more learning to do.

What did you do for his viral meningitis? Nothing except supportive care I would imagine. There are lots of people who get severe headaches with viral syndromes, and one could argue that if you LP'd every one of them, you would find that they have mild viral meningitis. Does it change management? Hardly. Most are just supportive care only.

Bacterial meningitis, however, rarely presents with rhinorrhea, cough, etc. This is the one you need to look out for since antibiotics are key to survival.

 

[elizabeth5863]

What did you do for his viral meningitis? Nothing except supportive care I would imagine. There are lots of people who get severe headaches with viral syndromes, and one could argue that if you LP'd every one of them, you would find that they have mild viral meningitis. Does it change management? Hardly. Most are just supportive care only.

Bacterial meningitis, however, rarely presents with rhinorrhea, cough, etc. This is the one you need to look out for since antibiotics are key to survival.

Hmm... I'm not sure what was done for the patient. We turfed him to the inpatient team, so I'm not sure how he was managed after the diagnosis.

 

[southerndoc]

Hmm... I'm not sure what was done for the patient. We turfed him to the inpatient team, so I'm not sure how he was managed after the diagnosis.

You admitted a viral meningitis? Wow. I can't say that I've ever done that before!

 

[Apollyon]

You admitted a viral meningitis? Wow. I can't say that I've ever done that before!

Happens ALL THE TIME at Duke. They go the whole gamut "just to be sure" ("they" being neurology).

 

[elizabeth5863]

You admitted a viral meningitis? Wow. I can't say that I've ever done that before!

Hmm... The only reasons I can think of are probably because of his persistent vomitting and fevers. I would imagine that the inpatient team probably kept him overnight for hydration and observation (for changes in mental status and neuro sx) and probably discharged him in the morning. I'm not sure how common it is to do overnight observation though but I saw it a lot at the hospital I was rotating at. But I was a just a med student... why argue with an attending?

 

[docB]

You admitted a viral meningitis? Wow. I can't say that I've ever done that before!

Yeah, we do that. I never did it in residency or moonlighting but that was in CA and they have the MICRA law. In Vegas malpractice is a real problem so we admit all the viral meningitis until the culture turns up negative. It's the "community standard of care."

 

[southerndoc]

Yeah, we do that. I never did it in residency or moonlighting but that was in CA and they have the MICRA law. In Vegas malpractice is a real problem so we admit all the viral meningitis until the culture turns up negative. It's the "community standard of care."

Interesting. So you keep them admitted for the entire 5 days until the culture grows nothing?

 

[Mumpu]

That's like a $5000+ bill for a self-limiting viral illness with no active treatment. Strong work.

A test should be done only if you are going to do something with the results, and your decisions should be driven by clinical suspicion and peformance characteristics of the test. And if your d-dimer comes back positive, for pete's sake, calculate the GFR and give patients NS and NAC.

 

[elizabeth5863]

Who is going to want to share their patient experiences if you guys are just going to bash at them? There's a difference between constructive criticism and pointing someone in the right direction and educating with tact vs. making people feel stupid and trying to point blame. Also, until med students and residents become attendings themselves, they don't make the final decision in certain management of patients. Whether an attending admits or not depends on his/her comfort level and the patient's condition. Also, we're here to treat individual pts and not the disease itself. Even if a pt has a condition that is self-limiting but is very ill, you're going to admit for observation. You're supposed to treat the individual pt and not the disease. If people (me included) are going to be afraid of sharing experiences because of what other people think and because of bashing, how are other people supposed to benefit by learning from other people's mistakes??? We're here to learn to prevent medical errors and to do what's best for the pt so stop being so mean.

 

[southerndoc]

Who is going to want to share their patient experiences if you guys are just going to bash at them? There's a difference between constructive criticism and pointing someone in the right direction and educating with tact vs. making people feel stupid and trying to point blame. Also, until med students and residents become attendings themselves, they don't make the final decision in certain management of patients. Whether an attending admits or not depends on his/her comfort level and the patient's condition. Also, we're here to treat individual pts and not the disease itself. Even if a pt has a condition that is self-limiting but is very ill, you're going to admit for observation. You're supposed to treat the individual pt and not the disease. If people (me included) are going to be afraid of sharing experiences because of what other people think and because of bashing, how are other people supposed to benefit by learning from other people's mistakes??? We're here to learn to prevent medical errors and to do what's best for the pt so stop being so mean.

I assume you are referring to Mumpu since I have said nothing out of line.

I respect docb's opinion. I was simply asking him if they keep the patient in the hospital until culture results come back negative (a process that takes 5 days before the lab at my hospital will report it as no growth). I'm also curious if empiric antibiotics are started in the meantime.

 

[docB]

Interesting. So you keep them admitted for the entire 5 days until the culture grows nothing?

The internists keep them until the 48 hour culture comes back. Yes, they keep them on antibiotics as if it's bacterial. Yes, it's all driven by fear of sending home the one in a million bacterial meningitis that looks like a viral on the initial CSF results.

 

[docB]

That's like a $5000+ bill for a self-limiting viral illness with no active treatment. Strong work.

A test should be done only if you are going to do something with the results, and your decisions should be driven by clinical suspicion and peformance characteristics of the test. And if your d-dimer comes back positive, for pete's sake, calculate the GFR and give patients NS and NAC.

Are you still trying to fight about that? Get over it and move on. Wasn't this thread about something else originally?

 

[southerndoc]

Are you still trying to fight about that? Get over it and move on. Wasn't this thread about something else originally?

I take it you guys know each other or have had some "experiences" on here?

 

[Apollyon]

I take it you guys know each other or have had some "experiences" on here?

That poster was - again - damning EM docs because we, in his words, don't get the "nuances" of medicine.

Strong words from an IM intern.

 

[Mumpu]

I'll leave the ER thing alone with the parting words that, unlike you, I actually see the follow-up to your actions (renal failure, prolonged antibiotics because only one set of blood cultures was sent, etc. etc. etc.). You do not know what happens after the move upstairs, and attitudes like yours are what keeps people from giving you that feedback. (Yes, EM is hard... you are busy, you are seeing a lot of patients, you have to make on-the-spot decisions. None of that is an excuse to provide inappropriate care though, is it?)

To go back to the original topic, the whole "two list" thing and all this great self-reflection is a) pretentious (woe is me, the self-tortured doctor who lies awake thinking about the terrible things I do to my patients) and b) fallacious in that it relies on retrospective analysis. A brain abscess that presents as viral URI will get a CT in retrospect but two tylenols when dealth with in real time. It is also difficult to tell premature closure of the differential from a patient whose badness simply does not declare itself on admission. This is why we watch, follow, and re-assess.

 

[LukeWhite]

the whole "two list" thing and all this great self-reflection is a) pretentious (woe is me, the self-tortured doctor who lies awake thinking about the terrible things I do to my patients) and b) fallacious in that it relies on retrospective analysis.

Not to point out the obvious, but everything we do in life relies on retrospective analysis; it's not possible to analyze things that haven't happened. The point of retrospective analysis isn't to say, "Gosh, I should have caught that dx earlier even though it was impossible to do so." It's to look at the natural history of the case and identify moments where a different intervention might have led to better results. I'm curious how you think things should be done, if this isn't the way you do it.

 

[Mumpu]

Why write a book about the obvious? No wonder it was written by Harvard faculty, the very self-proclaimed ivory tower of self-retrospective, uber-humane, kindly-yet-tortured doctors.

You are correct, we all do retrospective analyses. But I think that making lists and writing a book about them is wanking.

And now we have to deal with yet another thing our dreaded "smart because I read medical books" patients drag in.

 

[LukeWhite]

Why write a book about the obvious? No wonder it was written by Harvard faculty, the very self-proclaimed ivory tower of self-retrospective, uber-humane, kindly-yet-tortured doctors.

You are correct, we all do retrospective analyses. But I think that making lists and writing a book about them is wanking.

And now we have to deal with yet another thing our dreaded "smart because I read medical books" patients drag in.

Mainly agreed...popular medicine books do tend to be grating. I think docs could stand to be trained in some quality control, though. Much of what we've traditionally done in that department has been either anecdotal M&M water-coolering or deference to whatever the latest big study recommends.

What we *really* need is a culture of quality assurance, hard-core disciplined six sigma stuff, and this should be beaten into med students from day one. They should always be asking why things go wrong, how they can be done better, and what the precise steps to executing these improvements are.

As far as that goes, list making is like you say pretty touchy-feely. Not a bad start though, maybe, for the majority of docs who simply have no idea how to go about analyzing and refining systems on a day to day basis.

 

[Long Dong]

Who is going to want to share their patient experiences if you guys are just going to bash at them? If people (me included) are going to be afraid of sharing experiences because of what other people think and because of bashing, how are other people supposed to benefit by learning from other people's mistakes??? We're here to learn to prevent medical errors and to do what's best for the pt so stop being so mean.

Yes please continue to share with us. So those of us who are just starting can learn from this thread.

 

[E Yorrick Davis]

Why write a book about the obvious? No wonder it was written by Harvard faculty, the very self-proclaimed ivory tower of self-retrospective, uber-humane, kindly-yet-tortured doctors.

You are correct, we all do retrospective analyses. But I think that making lists and writing a book about them is wanking.

And now we have to deal with yet another thing our dreaded "smart because I read medical books" patients drag in.

I disagree with this last comment. I think it shows part of the thought process the book is trying to mitigate. It also shows a good degree of bitterness, which I guess isn't unusual for medicine residents but is still regrettable (and I thought Colorado was the 'happy' state).

Mumpu, it is surprising to me that your mindset has become this parochial so early in your training. I know this isn't Denver, but please don't brush off someone with ivy on their walls simply because they have ivy on their walls. And to be frank, your comments make me wonder if you've actually read the work, or if you might be prematurely generalizing it to be another 'one of those' books.

It is quite pointed that the arguments in this thread, so far mainly Mumpu vs. everyone else, are a central tenet of "How Doctors Think". Groopman tries to ferret out physicians that have this 'blame everyone but myself' thought process, and so far it looks like it's working.

Lukewhite, I agree with your observation regarding the parallels between Six Sigma and Groopman's list. Making a list is a way of taking the first three steps in any Sigma process. And I also agree with your point that if you are frank, it is more quantitative than the 'water coolering' seen at M&Ms. I believe the main question of the book was posed to the author at Tuft NEMC's Grand Rounds, actually (which is where AProgDirector is from?).

It would be quite fulfilling to watch medicine butt heads with the bottom-line mentality of the Sigma process. I wouldn't be surprised if we realized how much more of our thinking is based on territorialism and self-preservation (ie. CYA) than it is on a more rigorous and standardized self-assessment process. Hmm, where's that GMAT prep book.. perhaps I don't need a fellowship after all.

 

[deleted4401]

You guys are dead on - it didn't hit me until someone said it, but basically Groopman is gently using tenets of Six Sigma. In a soft way, but very definite, and I'd be skeptical if he denied it. It is exactly the sort of thinking we can use to get better at the practice of medicine. If we can't figure out why we make the mistakes we do or why we make the great diagnoses that we do, we're not going to be able to harness it later to reduce error and to increase our efficiency.

We can't even begin the analysis, interpretation, and recommendations without these 'lists'. I wish I had more to contribute, but I like reading everybody else's ...

-S

 

[Mumpu]

Oh, don't get me wrong. I intend to spend my career as a hospitalist doing a lot of QI and systems engineering work. I'm very much into all this stuff. I just think it's pretentious to make it all into a "here's a secret peek into the world of doctors" book which is exactly what you market when you publish something called "How doctors think." Just like my (and everyone else's) posts here, it is posturing and taking the high moral ground.

List #1 is basically uncommon presentations of serious illnesses. The key to managing these is not to pan-man-scan on admission but to learn to re-expand and re-explore the diagnosis if things don't jive.

List #2 is maybe 2/3s incidentalomas and 1/3 prior experience. The incidentalomas come from pan-scanning things from list #1. The experience comes from stepping back when things in list #1 don't fit neatly.

Now if you excuse me, I'm going to work on my list of patients on whom I forgot to order the AM labs during the admission process. I'll have a book out by August.

p.s. Colorado IS a happy place. I merely employ a healthy dose of skepticism and realism. Keeps me sane.

 

[E Yorrick Davis]

List #1 is basically uncommon presentations of serious illnesses. The key to managing these is not to pan-man-scan on admission but to learn to re-expand and re-explore the diagnosis if things don't jive.

List #2 is maybe 2/3s incidentalomas and 1/3 prior experience. The incidentalomas come from pan-scanning things from list #1. The experience comes from stepping back when things in list #1 don't fit neatly.

The application of six sigma to medicine is a relatively new concept--especially at a national, patient-based level. Also, a book that teaches patients how to ask pertinent questions (which this one does) is something that could save me a lot of pain and wasted time in continuity clinic, and anything that does that is worth its weight in Etanercept.

Despite the campy name that preys on the ER-Scrubs-Gray's-loving mainstream of America, the book is definitely a step in the right direction.

Alsoi, still don't think you read the book, or you'd realize the author only mentioned one type of list. I believe the second list was the OPs own contribution.

 

[tum]

yes it was my contribution. i think it was a logical extension of the first though.