I get tunnel vision when interviewing patients, any tips to avoid this?

[ohmanwaddup]

I'm a 3rd year in psych now and I have noticed this in the past as well, where I have a narrow view when interviewing patients and coming up with a ddx.

There was a patient last week experiencing only visual hallucinations with a previous episode some months ago. I could only think of psych/brain related causes, though when I went back into the chart later in the day I saw that right before her first episode she had a UTI, and lo and behold this time she had a urinalysis done and had a UTI as well.

I am unsure if this is the underlying cause as the patient's care was switched to another physician, but I was kicking myself a bit for not asking questions in the initial interview that were unrelated to psych, but could be causing the problems. I am able to do this sometimes, such as with chest pain cases, but overall this is a issue I have been struggling with for all of med school.

Is this something that will just get better with time? Does anyone have tips for slowing down their brains and helping with this?

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[Redpancreas]

I think this is a great discussion point. I don't think you're alone in this area and think it will improve with experience but since you've identified it as an area for learning I think there's a lot we can gain. Let's take what you have given and walk through it.

1.) Take your time eliciting the chief complaint and translate it to your chief concern: I see cats climbing on my dresser -> Acute Onset Visual Hallucinations. If you just grab "hallucinations" from the patient and go from there you're already screwed and I can tell you from experience your attending tomorrow will stop you right when you just say hallucinations and ask for more. Poor students don't even think to differentiate. OK students ask but don't include in their clinical reasoning process. Good students ask, include it in their reasoning. Excellent students, ask, include in their reasoning, and then have the verbal reflex to say "visual" in their presentation.

It's important to use a streamlined precise medical language in your head, on documentation, and while presenting. It will lead to better clinical reasoning and a quicker transition from seeing the patient, writing your note, and presenting the case. Auditory Hallucinations are typically related to a temporal lobe/schizophrenia related etiology whereas visual hallucinations can be specific to something such as LBD but also be related to metabolic encephalopathy (body's chemistry out of balance, brain waves interpreting stuff)

2.) Use the HPI to characterize your differential: Everyone has their own mnemonic but the thing with the mnemonics are that not every point is relevant to each case. An inexperienced medical trainee move that you're trying to avoid includes simply running through a mnemonic. Instead tease out some questions.

For this case here's what's important:
A) Duration: Long term points to potentially something organic/recurring. One thing which sticks out if this was chronic is Lewy Body Dementia. In this case its acute which should rule out a lot of chronic neuro stuff.

B.) Recurrence: You mention this is not the first time. Does this come in defined spurts or are the visual hallucinations always kind of in the background? The former can hint towards a recurrent systemic issue or exposure. Figure out what happened last time (hindsight is 20-20).

C.) Triggers: Try to find clues to support what you're already thinking. Any new medications? Is patient delirious or are they confused?

D.) Palliative (i.e. better or worse), Severity, Temporal association (night/day), and other HPI things. Ask family members if the patient does not have insight.

E.) Associated Symptoms->ROS: Ask them any associated symptoms they're able to identify without you prompting and then go through the ROS. Through experience you will learn to be thorough but focused (ex. no need to ask about vaginal bleeding, but UTI symptoms for sure).

3.) Medical history:
Things that would be important to include any chronic conditions/events/habits that could have led to the chief concern. You didn't list anything so for the purposes of this there were none. Things that might be relevant are dementia history, neurotoxic medications (antifungals, immunomodulators)

3.) Physical Exam:
Pertinent components to perform would be vitals, a neuro exam to rule out a focal neurological deficit, a screening for delirium.

4.) Basic Labs:
Take a quick look at what labs are available. CBC/CMP/Urine

5.) Assessment:
Ex) 77F with new acute visual hallucinations for a duration of 1 week associated with UTI symptoms, fatigue without recent change in medications, syncope, nor head trauma. Medical history and exam are non-contributory, basic labs demonstrate no electrolyte abnormalities nor end-organ damage, no leukocytosis but UA positive with nitrates.

After you've done that you can start your differential and further work up. Rank your differential and pick studies that you think will rule in what's most likely and rule out what you don't want to miss. That's the process from A-> Z in a nutshell.

 

[IMG69]

Don't worry it's just a time thing, fellow M3 and I used to tunnel in my earlier years but with more exposure to histories and the same 'histories' you essentially find the weaknesses in your history taking and become conscious of other things you may be missing.

Or the attending just straight up tells you what you missed.

General rule of thumb that I have picked up which I see some of my fellow students miss; if they have PMH (past medical history idk what you guys call it) ask how it is now. HTN - is it under control, hip replacement - how is it now etc. Doesn't have to be a long discussion, just yep it's good.

We're told to listen to every heart lungs etc that we can, take that notion with histories because it also means you'll have to do less osce prep when the time comes.

Practice makes perfect 🙂 don't sweat it too much.

 

[QuizzicalApe]

Some people use mnemonics to help force themselves to consider things they may not have. One that was used when I was in medical school was VINDICATE:

V – Vascular
I – Infectious
N – Neoplastic
D – Drugs
I – Iatrogenic (IE, what did I do to this poor person during their stay)
C – Congenital
A – Autoimmune
T – Traumatic
E – Endocrine/metabolic

Not meant for charting purposes, but walk yourself through that and ask yourself what in each category might cause the issues at hand. It will at least make you consider alternatives.

There are varying versions of this mnemonic and others as well. They're a useful crutch

 

[Redpancreas]

Some people use mnemonics to help force themselves to consider things they may not have. One that was used when I was in medical school was VINDICATE:

V – Vascular
I – Infectious
N – Neoplastic
D – Drugs
I – Iatrogenic (IE, what did I do to this poor person during their stay)
C – Congenital
A – Autoimmune
T – Traumatic
E – Endocrine/metabolic

Not meant for charting purposes, but walk yourself through that and ask yourself what in each category might cause the issues at hand. It will at least make you consider alternatives.

There are varying versions of this mnemonic and others as well. They're a useful crutch

This is essential to nail down to OP and I used this mnemonic for some time. To piggy back off of this post another strategy I use now is called the CT method. There's been a paper or two written about it in MedEd but it's essentially imagining a CT scanning the patient and trying to think of physiological reasons for why the patient is having the problem. For example, visual hallucinations. Start with the head and differentials include metabolic encepalopathy, focal neurological deficit (stroke, mass, etc.)..then eyes which could include potential partial retinal detachment, moving down to mouth I think anything the patient is ingesting like drugs, heart/lungs don't really mean much here, but then I go to the kidney and liver and think potential clearance issues (AKI, liver failure), etc.

If you really want to be diligent and it's the 5th day and you still don't know what's going on with your patient, you can combine the CT method with VINDICATE. For example, for the brain go through the whole VINDICATE mnemonic. It's usually low yield and only brings out academic zebras hence its lack of utility on day 1.

 

[ohmanwaddup]

This is essential to nail down to OP and I used this mnemonic for some time. To piggy back off of this post another strategy I use now is called the CT method. There's been a paper or two written about it in MedEd but it's essentially imagining a CT scanning the patient and trying to think of physiological reasons for why the patient is having the problem. For example, visual hallucinations. Start with the head and differentials include metabolic encepalopathy, focal neurological deficit (stroke, mass, etc.)..then eyes which could include potential partial retinal detachment, moving down to mouth I think anything the patient is ingesting like drugs, heart/lungs don't really mean much here, but then I go to the kidney and liver and think potential clearance issues (AKI, liver failure), etc.

If you really want to be diligent and it's the 5th day and you don't know what's going on you can combine the cross the CT method with VINDICATE. For example, for the brain go through the whole VINDICATE mnemonic. It's usually low yield and only brings out academic zebras hence its lack of utility on day 1.

This CT method sounds like a incredible mental tool to use for me and very much in line with how my brain works best. I am 10000% percent going to be writing it at the top of my notes as a reminder. If you have any links to those papers I would like to read up on it.

I remember vindicate being brought up 1st year. I am totally going to write that at the top too until it becomes second nature. Thank you so much everyone!

 

[Redpancreas]

This CT method sounds like a incredible mental tool to use for me and very much in line with how my brain works best. I am 10000% percent going to be writing it at the top of my notes as a reminder. If you have any links to those papers I would like to read up on it.

I remember vindicate being brought up 1st year. I am totally going to write that at the top too until it becomes second nature. Thank you so much everyone!

Do not write anything on the top of your notes! Notes are primarily for billing, keep your own mental notes separate or judgmental people will think something of it. Ex. Keep it as a sticky note on your workspace. The research does not have much power to it but here is the study I was referring to. I guess it's actually called "The Mental CT scan". Best of luck.

Teaching heuristics and mnemonics to improve generation of differential diagnoses - PubMed

<span><b>Background</b>: Differential diagnosis (DDx) is one of the key cognitive skills that medical learners must develop. However, little is known regarding the best methods for teaching DDx skills. As metacognition plays a fundamental role in the diagnostic process, we hypothesized that the...

pubmed.ncbi.nlm.nih.gov

 

[ohmanwaddup]

Do not write anything on the top of your notes! Notes are primary for billing, keep your own mental notes separate. Ex. Keep it as a sticky on your workspace. The research does not have much power to it but here is the study I was referring to. I guess it's actually called "The Mental CT scan". Best of luck.

Teaching heuristics and mnemonics to improve generation of differential diagnoses - PubMed

<span><b>Background</b>: Differential diagnosis (DDx) is one of the key cognitive skills that medical learners must develop. However, little is known regarding the best methods for teaching DDx skills. As metacognition plays a fundamental role in the diagnostic process, we hypothesized that the...

pubmed.ncbi.nlm.nih.gov

Thanks for the heads up!

 

[longhaul3]

Try not to think of the interview as a performance that you have rehearsed and are trying to get right. The point is that you need to get information that will help you make a diagnosis. This sounds obvious, but in med school we are trained to organize the history in X manner, ask Y questions, do Z exam maneuvers, and that leads to a tendency for med students to just try to act that out every time, and they think more about getting the performance right than the actual content of their interview.

One way to combat this is to come up with a differential before you see the patient. It's unrealistic and unnecessary to see a patient without reading the chart and looking at the imaging first (unless you're in the ED but they may already have a chart). By having a reasonable differential, you can remind yourself to ask relevant questions and do a focused exam.

I think in this way you think more along the lines of an investigator actually trying to get to the bottom of something than of an actor trying to replicate a rehearsal. You can slow down and think about what questions you actually need the answers to in order to come up with your answer, rather than checking off heat intolerance, cold intolerance, headache, abdominal pain, depressed mood, all these random ROS questions.

 

[Lawpy]

This is a good thread. Def adding this and SOAP note advise to the directory