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Hickam's dictum, Occam's razor, and Crabtree's bludgeon: a case of renal failure and a clavicular mass

Blaser, Simone; Schaye, Verity; Hwang, John; Cocks, Patrick; Kudlowitz, David
OBJECTIVES/OBJECTIVE:Our discussant's thoughtful consideration of the patient's case allows for review of three maxims of medicine: Occam's razor (the simplest diagnosis is the most likely to be correct), Hickam's dictum (multiple disease entities are more likely than one), and Crabtree's bludgeon (the tendency to make data fit to an explanation we hold dear). CASE PRESENTATION/METHODS:A 66-year-old woman with a history of hypertension presented to our hospital one day after arrival to the United States from Guinea with chronic daily vomiting, unintentional weight loss and progressive shoulder pain. Her labs are notable for renal failure, nephrotic range proteinuria and normocytic anemia while her shoulder X-ray shows osseous resorption in the lateral right clavicle. Multiple myeloma became the team's working diagnosis; however, a subsequent shoulder biopsy was consistent with follicular thyroid carcinoma. Imaging suggested the patient's renal failure was more likely a result of a chronic, unrelated process. CONCLUSIONS:It is tempting to bludgeon diagnostic possibilities into Occam's razor. Presumption that a patient's signs and symptoms are connected by one disease process often puts us at a cognitive advantage. However, atypical presentations, multiple disease processes, and unique populations often lend themselves more to Hickam's dictum than to Occam's razor. Diagnostic aids include performing a metacognitive checklist, engaging analytic thinking, and acknowledging the imperfections of these axioms.
PMID: 34355545
ISSN: 2194-802x
CID: 4988732

[S.l.] : Core IM, 2020

Stories During Challenging Times

Kelleher, Solon; Uloko, Maria; Kalet, Adina; Arora, Vinny; Rafei, El; Hwang, John; Trivedi, Shreya P; Desai, Brinda
CID: 5325852

The hoofbeats/coreim series: Podcasting as a promising medium to explore the language of clinical problem-solving [Meeting Abstract]

Hwang, J I; Sachs, S A; Ou, A; Trivedi, S P; Fried, M; Shapiro, N; Fang, C
Needs and Objectives: Superior clinical reasoning is a hallmark of the expert clinician. However, to a passive listener at a traditional case conference, the process by which this expert arrives at a diagnosis may not be obvious. Discussion often focuses on medical knowledge, rather than on the Methods the expert uses to reach a Conclusion. Experts vary in their ability to describe how they approach a case, and it is debatable whether narratives produced in this manner are in fact reliable representations of their mental processes. Teaching clinical reasoning can thus be challenging even for experienced faculty. In response, we designed a podcast series using actual cases to explore the conscious and unconscious habits and strategies used by physicians. Our intention was to immerse listeners in the language of clinical problem solving in an accessible and interactive way. Setting and Participants: Hoofbeats is one of several series that comprise the CoreIM podcast. It is targeted at trainees and medical professionals across all specialties within internal medicine. Description: Hoofbeats listeners play the role of the clinician, as a difficult case is presented in stepwise fashion with pauses to allow revision of an impression or differential. Listeners hear a discussant work through the case, accompanied by commentary from the show's hosts, who interpret and elaborate on the discussant's reasoning behaviors. Clinical pearls, useful schema, and biases are highlighted. To reinforce the challenge, a visual representation of the case is sent out via social media. In some episodes users can solve an interactive version of the case on the online database HumanDx; the resulting collective differential is then explored within the episode. Evaluation: From March to December 2018 we released six Hoofbeats episodes, with over 64,000 total downloads by listeners across 170 countries. In our descriptive analysis of feedback, we found that listeners valued the explicit analysis of the problem-solving behavior of experienced clinicians. Interactive elements successfully engaged our listeners, who actively attempted cases and reflected on their reasoning. Through role modeling from the hosts, listeners reported greater confidence articulating and teaching clinical reasoning concepts. Interestingly, commentary on particularly challenging points in a difficult case led our listeners to appreciate the honesty and humility of our hosts and experts, who frequently recognized their own shortcomings. Discussion/Reflection/Lessons Learned: Decades of research into clinical problem-solving have produced a terminology now familiar to many trainees and medical professionals, such as the practice of "problem representation" or the concept of the "availability heuristic." Many of these abstract concepts originated in behavioral science and artificial intelligence programming, and do not lend themselves naturally to book or lecture-based learning. However, our experience with Hoofbeats suggests there is significant interest among learners in the practical application of these constructs
ISSN: 1525-1497
CID: 4052592

Core IM: A novel medical education podcast steeped in learning theory [Meeting Abstract]

Fried, M C; Hwang, J; Liu, S; Shapiro, N; Trivedi, S P
Needs and Objectives: Because of high patient turnover, decreased length of stay and onerous documentation requirements, today's clinician has great difficulty incorporating traditional learning into their day. Podcasts are a perfect medium to allow physicians and students to learn at a time and location of their choosing. Traditional podcasting is a passive endeavor. Even the most engaging podcasts haven't yet incorporated evidenced-based learning strategies. 1. We aim to create engaging, high-yield podcasts that use active learning strategies to boost retention over time. 2. Podcasts are augmented by artistic depictions and show notes, which offer mutually-reinforcing perspectives on each segment's key learning points. Setting and Participants: This educational innovation is internet-based and open to anyone. Thus, the setting is anywhere. Our listeners include medical students, residents, faculty and allied health professionals. Description: The typical CORE IM podcast runs 10-20 minutes. To ensure accuracy of the information, the podcast script is peer reviewed by a specialist in the field. Each podcast is augmented by drawings demonstrating key teaching points as well as show notes. Currently we are offering 2 bi-weekly segments: 5 pearls: Hosts explore 5 evidenced based pearls on a core internal medicine topic. Introductory questions prompt listeners to retrieve prior knowledge. A clinical pearl from a recent podcast is also reviewed based on the principle of spaced repetition. Mind the Gap: This segment takes a closer look at the evidence-or lack thereof-underpinning common clinical practices, in order to expose knowledge gaps and challenge dogma. Over the coming months we are planning new offerings: Hoofbeats: a case-based segment that will explore the reasoning techniques used by experienced diagnosticians discussing the case. Gamechangers: an appraisal of recent literature to determine if the results of a study ought to inform our clinical practice. Evaluation: From October to December 2017, we released six podcasts with more than 11, 000 total downloads. We have listeners in over 90 countries, from every discipline within medicine. Analysis of feedback on downloading platforms indicates that our listeners value the focus of the podcasts, the priming questions, and the review of take-away points at each segment's end. Discussion/Reflection/Lessons Learned: Incorporating evidence-based instructional strategies within podcasting allows learners to better retain new knowledge at their own time and pace. Visual learning also empowers learners to review teaching points from a different perspective. The feedback and growth of our listenership suggest that this combination can be a sustainable source of self-directed learning. Moreover, learning that occurs on platforms irrespective of training or field and beyond the physical borders of an institution unlocks the potential for exciting interdisciplinary discourse among all types of providers involved in patient care. Online Resource URL (Optional): 3A__bitly.com_2zHuixk&d=DwIBAg&c=j5oPpO0eBH1iio48DtsedbOBGmuw5jHLjgvtN2r4ehE&r=vQfPybH YMptZTsGTKf8YZN_ho-QhkqmSqA9bfoe84p4&m=dTRc5akIhNSA47ZIK1KHte11C- tDaMMQxvCxqAX06Ps&s=bKVMH_gnpa-ABH9jwRa_PeW-3W2bHq-BHl-6UCsiJIE&e=
ISSN: 1525-1497
CID: 3138992