Intentionally seek deviations to avoid early anchoring
In a new series, Pearls from I.M. Peers, Maria (Gaby) Frank, MD, FACP, explains how noting variations in expected patterns can help internists avoid early anchoring errors when making a diagnosis.
As physicians, we get trained to identify patterns, which is helpful to make a quick diagnosis and treat patients accordingly, as quickly and efficiently as we can. Even though patterns are helpful, I try to usually focus on identifying inconsistencies in the patterns. We need to avoid anchoring too quickly on a patient's diagnosis or presentation. I like to use inconsistencies as a way to prevent early anchoring and diagnose patients correctly.
The time that we spend face to face with the patient is key to any diagnosis. We can get a lot of information from that, especially now that physicians spend more time in front of the computer and a decreasing amount of time face to face with a patient. When we are face to face with a patient, we need to be very intentional about listening to what the patient has to say to us. Pay attention to every detail as well as observing what the patient is displaying. Do they have any rash? Will that rash change what I'm thinking about chest pain or pneumonia?
I use the word “intentional.” We need to be very intentional when we're face to face with a patient and avoid spending time on the computer when we're talking to the patient. We're going to miss all the other cues that the patients are displaying for us if we're actually trying to get history and writing notes at the same time. Try to dedicate the time that we're face to face with the patient to actually do that: Be face to face, observe, and listen to the patient.
It's important to actually look at where a patient is pointing to when we ask, ‘Where does it hurt and when does it hurt?’ We shouldn't ask those questions just out of reflex. We need to pay attention to what the patient says because that can lead to rule-outs and diagnoses.
I had been called to see a patient, a young female who presented with chest pain. They wanted to do an evaluation because she had a mildly elevated troponin level. When we think of acute coronary syndrome pattern, we often think of a patient with cardiovascular risk factors, middle or advanced age, presenting with left-sided chest pain or its equivalents, with or without an elevated troponin level. We ruled out an acute coronary syndrome in this patient. In this case, the patient was female and 24 years old, which easily became an inconsistency. Even though not impossible, acute coronary syndrome is not usually what we think about when we see a young person presenting with chest pain.
I'm kind of old school. I like to say the history and exam will provide us most of patients' diagnoses. I took a deeper history. This patient's mother had a history of thromboembolic disease and was on lifelong anticoagulation, but the patient never had any symptoms of thromboembolic disease before. She described a “doom” sensation when she was walking in the mall and developed sudden chest pain on the left side that started radiating to the left upper extremity. She saw that her hand had turned dusky, and then went back to a normal color. When examining the patient, she didn't have a radial pulse on the left hand, which helped us to make the diagnosis rather than trying to do an acute coronary syndrome rule-out. She actually had a large thrombus that extended from the axillary artery all the way to the distal brachial artery. I'm not saying that no one else would have uncovered this. I'm just saying how important it is to get outside of our patterns and explore a little further.
