Thinking Activity In Medicine

Doctors are supposed to be smart. In most countries a student needs several years of higher education in order "prove themselves" and get into medical school. Information retention is important in medical school but a higher emphasis is put on solving problems. Thinking as an activity is really only studied in epistemology, a field of  philosophy. The following cases show how important understanding thinking is in making the right, often life-saving, diagnosis.

1. Pigeon-Holing

pigeon holing

One of the most common errors in diagnosis is pigeon-holing. This occurs when a doctor forces a cluster of symptoms inappropriately into the wrong workup pathway. There can be many reasons for this. A common saying is "if you don't think of it, you won't diagnose it." If the concept is not in our heads due to lack of experience or lack of study- we may not even think of the real reason for a problem. Many of these errors act in concert with each other.

One popular path of treatment is the "chest pain work up." This path entails looking for life-threatening problems like pulmonary embolism (blood clot in the lungs), aortic dissection (ripping open of your biggest blood vessel), and heart attack in a person with chest pain. It is possible that pain in the upper belly can be a heart issue. I have seen patients given a huge and expensive work up for chest pain when every symptom pointed to their gallbladder- this can be a tricky balance as it may be reasonable to rule out heart/chest pathology before chasing down the gallbladder.

The solution here is a little patience- gather more percepts (listen to the patient and look at tests) before jumping to a conclusion. 

2. Diagnosis Fatigue

diagnosis fatigue

We just admitted three patients with shortness of breath. The fourth patient also has shortness of breath. The three prior patients all were effectively ruled out for blood clots in their lungs. Surely this patient doesn't have a blood clot! And they have borderline kidney function so we don't want to order a CT scan to rule them out as the iv contrast dye might cause complications. We convince ourselves that we don't need to think about this diagnosis. It is just some bad bronchitis. This could have fatal results (I have seen this). The treatment of blood thinner is very different than the treatment of breathing treatments, antibiotics, or steroids. 

We need to keep an open mind and not allow prior patients' results affect our current situation.

3. Red Herring

red herring 

Too often do we find an abnormality in a diagnostic test and place undue weight on this result. The most common places I see this error in thinking is diagnosing a urinary tract infection and pneumonia. A urine test often will show some signs of white cell activity in the urine and even signs of bacteria. Sometimes this is related to not having a clean catch sample and cells from the outside contaminating the sample. Sometimes it is an indwelling catheter and other times it is asymptomatic bacturia (this only needs treated in pregnancy). With pneumonia commonly a chest xray shows a possible abnormality that could be atelectasis (squishing together of the lung from laying in bed too much). The problem with red herrings are that the treatment may be misguided and the work up may be stopped too soon.

Solutions to red herring is to always question yourself at least a little. Wait to make the final diagnosis.

4. Soothing Thoughts 

no evil

It is possible to talk ourselves out of a diagnosis that we know is correct. This patient is not septic- they are a little nervous that is why their heart is beating faster and they are breathing hard. They are dehydrated, that is why they have a high white blood cell count. The right concept is there, we just talk ourselves out of it. It is alright to doubt ourselves- and even healthy- but we should have a back up plan. Which tests or treatments can we order to try to verify that we are right or wrong? 

5. Living in the Fast Lane

fast lane

When we are rushed it may be impossible to not not be biased in the above ways. It is important to not allow the stresses of a job influence our objectivity and to always listen (95% of the time the diagnosis can be made simply by speaking with a patient). If we are stressed and rushed the world may close itself off to us. Medicine today is far too rushed. This is a reason the direct primary care model has become so popular- patients and doctors don't feel rushed anymore and the right diagnosis and treatments can be found.

Try to have an inner barometer of how rushed and stressed you are. If you feel hurried- take time to slow down. 

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