Tips for expanding differential and coming up with comprehensive plan?

[Redpancreas]

So I got my midyear feedback back for my intern year and I have good evaluations because I am a hard worker, follow up on things, and am knowledgeable but something that sticks out that most attendings say is that I am 2/5 (novice) for "coming up with a comprehensive plan". I really struggled with this in medical school possibly because I relied too much on pre-made notes and I feel like it's a struggle for me to do complete work ups on patients and think because of all the data tracking, orders, etc. that I do in the morning to really think about the nuances of why a hemoglobin may be low...yesterday everyone thought it was his chronic disease...now they're second guessing it...I know this is a really vague area but any responses specific or vague would be appreciated. One attending said that I find that when asked a question, you nearly always have the correct answer but don't always put things together when coming up with a differential diagnosis or plan.

Would really appreciate advice as I want to genuinely be an extremely strong resident and this has been a bit of a setback, albeit a slightly expected one because I know this would eventually come out.

Often when I'm asked about a differential for let's say back pain, I'll rattle of some things and they're like good, good...and I seem to have correctly answered their questions. In notes, I'll rank possibilities (differentials) based on labs, history, etc. but it does seem like I'm not doing something right and perhaps there's a bit of anchoring. When seniors and I compare plans on admitting notes, they do a more thorough job I suppose, but like we both come up with the major things I suppose.

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[Palindr0me]

Your best best is going to be sitting down with your attendings and having them run through what a comprehensive plan looks like — whoever is evaluating you obviously should have constructive feedback in terms of actualizing that potential rather than just giving you nothing to work from.


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[IMreshopeful]

I think the key here is trying to expand beyond what you think is going on. One of the big mistakes I saw interns doing is basically pigeonhole themselves into the diagnosis the ER gave a patient when admitting them. Sometimes the ER is spot on, but often they’re also not - and that’s a function of them trying to triage the patient and work with a limited set of tests. The PNA that was billed to you could actually be a CHF with severe MR, an interstitial pneumomitis, a drug reaction, etc etc. That volume overload might not be CHF - what about renal failure, cirrhosis, iatrogenic salt loading, etc.

The flip side of it though is that I feel like some academic GIM folks get bogged down in the weeds. Some will obsess over the Hgb trend or the mild thrombocytopenia (especially irritating when it’s a chronic problem) or try to do a full rheum workup for knee pain that’s clearly OA etc. it’s true after all that IM requires you to be detail oriented but I feel as though some folks take that to mean becoming pedantic and OCD about meaningless details.

To be honest few interns I’ve had on my services have been stellar doctors. They usually had to meet a small set of goals - don’t kill patients, know when someone is sick and be able to work up/stabilize, and try to be as efficient and timely as possible. It requires a long learning process to improve to the level of a strong well rounded medicine physician and it’s just going to develop over time

 

[PlutoBoy]

So I got my midyear feedback back for my intern year and I have good evaluations because I am a hard worker, follow up on things, and am knowledgeable but something that sticks out that most attendings say is that I am 2/5 (novice) for "coming up with a comprehensive plan". I really struggled with this in medical school possibly because I relied too much on pre-made notes and I feel like it's a struggle for me to do complete work ups on patients and think because of all the data tracking, orders, etc. that I do in the morning to really think about the nuances of why a hemoglobin may be low...yesterday everyone thought it was his chronic disease...now they're second guessing it...I know this is a really vague area but any responses specific or vague would be appreciated. One attending said that I find that when asked a question, you nearly always have the correct answer but don't always put things together when coming up with a differential diagnosis or plan.

Would really appreciate advice as I want to genuinely be an extremely strong resident and this has been a bit of a setback, albeit a slightly expected one because I know this would eventually come out.

Often when I'm asked about a differential for let's say back pain, I'll rattle of some things and they're like good, good...and I seem to have correctly answered their questions. In notes, I'll rank possibilities (differentials) based on labs, history, etc. but it does seem like I'm not doing something right and perhaps there's a bit of anchoring. When seniors and I compare plans on admitting notes, they do a more thorough job I suppose, but like we both come up with the major things I suppose.

Be systematic. Address every issue separately.

For every complaint and significant lab abnormality, make a note and a differential/plan. You may end up repeating yourself but you won’t miss a lot of stuff this way.

 

[mercaptovizadeh]

Hmmm, I'd say use the chief 1-2 complaints as your anchor, then look at the past medical history both recent and remote AND the physical exam AND medications (people forget adverse effects all the time) and formulate a differential through the lens of that past medical history while not anchoring yourself to particular diagnoses unless it is patently obvious.

For example, you have a lupus patient with shortness of breath. Your basic differential will be pulmonary disease, cardiac disease, anemia/O2 carrying impairment. You can't necessarily test for every single thing on the differential. However, you learn your patient is on prednisone, plaquenil, MTX, and recently was started on dapsone for hard to control lupus rash. She's missed a few inhaled pentamidine appointments and is allergic to TMP-SMX. You'll probably have an X-ray and basic labs from the ED by the time you see the patient.

Let's say she has bilateral interstitial and GGO, cough, minimal edema, and anemia. She also has decent O2 sats but seems more dyspneic than you would expect in the low-mid 90s. At this point the SLE history should prompt you to consider new onset CHF, possibly from ischemic disease or pericarditis or myocarditis or an arrhythmia or plaquenil cardiomyopathy, interstitial lung disease or pneumonitis from SLE or a medication such as the MTX, pulmonary vasculitis (very rare in SLE) perhaps prompting an ANCA/DAH workup, opportunistic atypical infection (PJP, Legionella, mycoplasma, histoplasma, viruses, etc.), with a contribution from anemia (check hemolysis labs, was G6PD tested for? is this an AIHA?) and possibly methemoglobinemia (because of her dapsone). You'll have to use the rest of the history, the timeline of events (acute vs chronic) and prior studies to help you decide about a chest CT, TTE, EKG/tele, whether to formally evaluate for a PE, assessing SLE disease activity, what anemia labs to send, and blood gas/co-oximetry. Once you've nailed down the presenting complaint and have instituted appropriate evaluation and therapies (and assess if empiric therapies can be held until more data comes back), start following up on other things like the usual adjustments you make to meds for chronic issues (withholding or titrating as appropriate), abnormal lab values that are not directly related to the chief complaint but still need to be addressed (her UA has 3+ protein, order a Uprot:Cr ratio), and other complaints (e.g. she's quite anxious, is it because of her dyspnea, because of a baseline anxiety issue, or she has neuropsychiatric SLE - and does this require psych consultation, brain MRI, or just fixing her dyspnea, or a combination of these?). The more finessed part of things is anticipating keeping someone NPO for a potential bronch the next day and making insulin adjustments accordingly, holding antihypertensives and diuretics when they're ill appearing in anticipation that AKI might occur down the line, recognizing the risk of adrenal insufficiency and parameters for instituting stress dose steroids, etc.

I think all of this will come with time, but basically it requires an attitude of rationally excluding serious/dangerous conditions while honing in on the most likely cause and treating in a fashion tailored to the data as it comes. Given the above example, I think you can see that deciding it was just one of the above conditions (e.g. PJP pneumonia) while abandoning the rest of the workup (or at least consideration of whether it could be contributing) would constitute less than ideal care.

 

[Rads Consult]

Start with anatomy and then go from there. At least that's how radiologists think about things when they see something weird. We ask "What lives there?"

It sounds stupid, but it's actually very effective. If you know what lives there, you'll often be able to then make the leap to all the things that can go wrong in that location. For example, chest pain. You can go through everything from lungs, vessels, pleura, heart, coronaries, myocardium, pericardium, esophagus, chest wall, trachea, bronchioles, alveoli, etc. once you break it down like that, you'll be surprised at all things you can come up with that can go wrong with that anatomy.

www.radsconsult.com

 

[DrSnips]

Start with anatomy and then go from there. At least that's how radiologists think about things when they see something weird. We ask "What lives there?"

This is an excellent strategy. Other than pattern recognition (which comes with time) I have two other strategies I also use:

VINDICATE mnemonic. Come up with as many ddx as you can for the CC in each category of vascular, infectious/inflammatory, neoplastic, drug-related, iatrogenic, congenital, autoimmune, traumatic and endocrine related.

The last trick I use in cases where the above didn't work is take the patient's rarest symptom, generate a ddx and cross-reference it with the second rarest symptom's ddx.

From there your comprehensive plan includes 1) testing that will distinguish between the ddx items that have the highest pre-test probability and 2) empiric treatment for the most-likely and/or most deadly items on the ddx wherever benefit outweighs risk.