Waggoner-Fountain_511_Assignment #6
Last week I was in clinic with an acting intern and we saw several patients together. He is a motivated learner and a pleasant young man. On Friday evening when I had time to sit back and reflect on my very busy day in clinic, I recognized there were some teaching opportunities that I used when I worked with him and there were some teaching opportunities I did not use with him.
Matt evaluated a patient and presented his evaluation to me. Hailey is an 8 year old female who had the chief complaint written by the receptionist as “fever, headache, sore throat”. Matt presented this girl with a temperature of 38.7, pulse 86, which he remeasured at 116, RR 24, BP 106/68. He described her as though she didn’t feel well and tired appearing. She had symmetrically enlarged, erythematous tonsils with some ‘whitish things that I don’t think are exudates”. He reported that her lungs were clear and he thought her heart rate was faster than was recorded so he took it himself. He also reported that the patient had a headache for the past 24 hours and abdominal pain. She did not have emesis, diarrhea, rash. She had a past history of strep throat last school year. Matt had obtained a rapid strep test which was negative.
I asked Matt for his differential diagnosis and he told me he thought it was going to be strep throat but wasn’t so sure with the negative rapid strep test. (Commitment) I asked Matt what might be other potential diagnoses and he said, “I guess it could be a virus”. I told him that he knew the answer to my question but we would go in and see her together. I asked him to think about this girl as if it was in January instead of October 2nd.
When we went back in to see the patient together, I asked her about muscle aches which she did have. She also had a cough when I questioned her. I confirmed everything he noted on his physical examination. We talked about the whitish things as being concretions rather than exudates. I went on to tell the patient’ smother that I thought she had H1N1 influenza and we discussed treatment options and the particulars of supportive care.
When we walked out, Matt said, “I thought kids with influenza looked worse than that” and he asked me how I knew that was the diagnosis and I said, ‘Well, because we are in the middle of the epidemic and she fit the case definition.” I also told him that her eyes looked like someone who has influenza (fatigued and minimally sunken, not as though dehydrated but more like someone who was grieving.” I could tell he didn’t understand the eyes component so I asked a partner to help me explain the ‘sick eyes’ that mothers report. We agreed it was something you learn to appreciate after your first 1,000 patients.
There were many teaching points some of which I covered.
1. I had Matt make a commitment about his likely diagnosis .
2. I congratulated Matt on thinking about strep throat and getting a throat culture. (analytic process).
3. I gave him the CDC case definition of H1N1 influenza and treatment options from the CDC (analytic process)
4. I discussed how H1N1 in children has more GI symptoms than in adults (analytic process)
5. I confirmed his estimation that the whitish stuff on the tonsils was not exudates. (non-analytic)
6. I discussed the ‘picture’ of a school age child with influenza (non-analytic process)
Both the student and teacher used an interaction of non-analytic and analytic processes.
Teaching points or biases I did not address but should have.
1. I should have congratulated Matt on rechecking the vital signs because this was important and he was right on the money. (non-analytic process by student)
2. I should have confirmed that this indeed was a viral process and should have made Matt tell me specific viruses that could cause this clinical case. (analytic see #3 for next step)
3. I could have had Matt use the Isabel program we have on our health sciences library website which would have had him put in key signs and symptoms and gives a differential diagnosis based on these signs and symptoms. (analytic process that can be initiated by the student)
Cognitive Biases that were evident
1. Availability bias – The medical student had read the worst case scenarios of H1N1 influenza as this has been splashed all over the media rather than reviewing the medical literature
2. Confirmatory bias – Matt was led down the garden path with a history of strep throat so he really thought that is what this child had until the rapid strep test was negative.
3. Putting initial probably at too extreme a figure and not adjusting for subsequent information (see #2 in Cognitive Biases section)
4. I should have reinforced the concept of a febrile respiratory illness with headache and myalgias are strong diagnostic clues for the diagnosis of influenza regardless of the time of year but to realize there is a spectrum of illness associated with influenza infections.