Published in the January 2007 issue of Today’s Hospitalist.
As the patient arrives from the emergency department, the ED physician tells you that the patient has cellulitis on her foot. While the presentation seems atypical, the foot is red and painful, so you prescribe antibiotics.
When she doesn’t respond to treatment after one and then two days, you decide to take a second look. After you drape the sheet over her leg, the patient yelps in pain, and you now have a new diagnosis: forefoot gout.
The case of the misdiagnosed cellulitis is a relatively common example of the types of errors physicians run into when making clinical decisions. For Sanjay Saint, MD, MPH, a practicing hospitalist and research investigator at the
Ann Arbor VA Medical Center, it also represents a type of incomplete data-gathering. Even more importantly, the case illustrates how the shortcuts that physicians regularly take-in this case, following the lead of a colleague-can backfire.
While Dr. Saint may be best known as a national expert on hospital-acquired infections, the topic of clinical decision-making is another one of his passions. He serves as special correspondent for the New England Journal of Medicine’s clinical problem- solving series and recently co-edited a book on the topic.
But his greatest source of authority on how physicians solve clinical problems comes from his hospitalist practice. The patient with the presumed cellulitis, for example, was one of his own.
In that situation, he says he fell prey to a type of error he calls an "anchoring heuristic," where you start your decision-making process with a certain reference point, instead of at the beginning. In this instance, the reference point was another physician’s diagnosis.
"If I had seen the patient de novo," says Dr. Saint, who is a professor of medicine at the University of Michigan Health System in Ann Arbor, "I would probably have thought about other diagnoses before deciding on cellulitis." But because his thinking was already anchored to cellulitis, "I needed more information to change my diagnosis."
"Think about your thinking"
According to Dr. Saint, the trick is knowing when something isn’t quite right and needs a second look. The solution, he says, is to "think about your thinking" and monitor the cognitive processes that guide your decision-making.
"As you’re looking at a patient and thinking she has cellulitis," he says, "ask yourself why you think she has cellulitis." If the only reason is because the ED physician told you so, ask yourself what else the patient could have.
While that may sound time-consuming, Dr. Saint says this kind of mental self-assessment becomes automatic-and isn’t needed when a diagnosis is crystal clear. He refers to this type of self-monitoring as "meta-cognition," and says it’s something that master clinicians engage in all the time.
Tips from master clinicians
According to Dr. Saint, physicians who are particularly adept at clinical decision-making are using what he calls "illness scripts" that are based on years of seeing common conditions. He is particularly fascinated by the way physicians apply those scripts.
"There may be some red herrings" he says, "but master clinicians are able to discount things that a novice would run after."
While gaining years of experience is one way to develop a sixth sense in clinical problem-solving, Dr. Saint will discuss other strategies early this year at the Spring 2007 Hospitalist CMESeries. During his presentation, he’ll walk audience members through a case study that illustrates the type of clinical-decision making detours that physicians often take.
And while no one likes to talk about his own errors, Dr. Saint will discuss the top 10 factors that lead him to miss diagnoses during his hospitalist practice.
What’s the point? That a little self-reflection goes a long way in avoiding errors. "When I miss a diagnosis," he explains, "I think about why I missed it so I can get better."
Sanjay Saint, MD, MPH, will discuss clinical problem-solving at the Spring 2007 Hospitalist CME Series being held in Los Angeles/Redondo Beach on Feb. 11-12 and in Boston/Cambridge on March 11-12. For more information, go online.