It’s day 5 of the Boxing Day test. You have great tickets and are catching up with some old mates. You’ve been to the MCG many times before but not in the last few years. You wake up late – too late to catch the train, so you jump in your car. On autopilot you follow the route you know well. Just outside Flinders St Station, with the MCG in your sights, the traffic stops – there is a Fun-run on today as well and the streets around “The G” are closed. You’re stuck with no where to turn around. You flick on the radio to hear the commentary and the crowd roaring as the first ball is bowled to the Brits and then you wait in the sedentary traffic……and wait. You’re madly googling alternative routes and even consider parking the car and walking the last 1 km to the ground. Your mates are texting and calling to see where you are and you can hear they are already full of frivolity. On the first ball of the sixth over, the commentator, deftly describes the ‘most fabulous catch of this test’ to take the first wicket. The catch was taken in the outfield, just in front of your awesome seats – and you missed it. If only you’d planned you’re route more carefully today and looked at the traffic conditions.
We make decisions all-day, everyday. We rely on balancing our knowledge and experience to tackle known and unknown challenges. We use the same process when we make clinical decisions, and answer questions in exams like the KFP. So thinking about clinical reasoning can assist in approach to day to day decisions and those that we have to make in our practice of medicine and in the exam.
The last couple of blogs have explored some common clinical biases affect clinical reasoning:
- Anchoring, information, and availability bias: When you can’t see the forest for the trees
- Overconfidence: Removing your clinical blinkers
- Risk tolerance: How much risk do you tolerate
- Bandwagon bias: Jumping on the Bandwagon
Even on a trip to the cricket these biases creep into our decision-making. We often rely so much on our past experience and patterns of behaviour that we forget to mitigate for unforeseen circumstances. If we make decisions by patterns in clinical practice or in the KFP, we will miss the unexpected (and potentially serious things).
So let’s have a look at how we make a diagnosis and how this might help us in our clinical decision-making and exam performance.
If we recognise the patient’s presenting symptoms match a diagnosis we have already seen, then we make a provisional diagnosis (pattern recognition), reinforced by our ‘gut feel’ about the patient. We often ask more questions to make sure the pattern fits (confirmation, information and availability bias). If all the clues line up, we make the final diagnosis, BUT we often forget the checks and balances required to ensure there are no possible alternatives, especially if we are overconfident and risk tolerant. If we encounter a problem we haven’t seen before, we change our tact. When uncertainty prevails we cast our net wider, generate a broader differential list and test each hypothesis (hypothesis/deduction) we are making about the diagnosis by using probing and clarifying questions. Because the diagnosis is not certain we tend to use more checks and balances (red flags and safety-netting) before coming to a conclusion. So it is the ability to recognise the importance of checks and balances (and apply them) that makes us accurate clinicians – that’s what the KFP is trying to assess, because checks and balances = competent and safe doctors.
There should be as much importance placed on exploring the alternative diagnoses as confirming the obvious one.
Given that the KFP is just over a month away, how do we turn these concepts into a practical strategy? Here are my tips for approaching the clinical scenarios (think of them as clinicial scenarious rather than questions):
- Read the stem (not the rest of the questions)
- Consider the patient’s age, gender and initial presenting complaint (not all the other information).
- Generate a differential diagnosis – use a surgical sieve like VINDICATE or VITAMINCDEF to make sure you ‘catch’ all the possibilities.
- Read the stem again (not the questions) focusing on the key features.
- Refine your differentials using the key features – rank them in order of most likely and consider the diagnoses not to be missed.
- Think about what Domains of General Practice the question might be exploring.
- THEN answer the questions.
- When you have answered the questions, apply the CAATCHHH technique to check your answers. I suggest you download the pdf and have it next to you when practising for the next few weeks. The technique is particularly helpful for the topics you have least confidence with or find it hard to generate answers for.
Remember to keep to time (7.5 minutes/question). Although the technique means you are spending longer thinking at the ‘front end’ of the question, it saves time later on as you’ve already come up with some of the answers. More importantly, it helps to remedy pattern-recognition and premature closure (jumping to conclusions too early) as it keeps your differentials broad in the first instance.
Day 5 of the cricket is just about to start, and luckily I am not stuck in Melbourne traffic. Please feel free to comment on the weekly clinical reasoning case in the our Facebook Group and let me know how the CAATCHHH technique is working for you. Enjoy the cricket!