Teaching use of Time as a Diagnostic Tool
September 22, 2013
Medical students and residents learn a hypothetico-deductive approach to clinical problem solving. This approach is enshrined in the ritual of the morning report. The focus is on developing a differential diagnosis and then a plan for ordering further tests to rule out or rule in various diagnoses. The question our students learn to ask is, “What are the possible diagnoses and what tests do we need to order to confirm or refute them?” Since a large part of the training occurs in the hospital setting where the focus is on shortening the length of stay, they come to accept a shotgun approach to test ordering to get at the answer as soon as possible.
When these trainees rotate through ambulatory settings, where practitioners are more comfortable handling uncertainty and with using time as a diagnostic tool, they may struggle. Faced with multiple patient complaints in a short visit, they need to learn to ask, “What do I absolutely need to do right now and what can I safely defer?”. Now, when the importance of value-based care is being increasingly recognized, this is an important question to ask. How can we as clinician educators, help them learn this approach? The answer may have been provided by Dwight Eisenhower.
Eisenhower is supposed to have said, “What is important is seldom urgent and what is urgent is seldom important” This is the basis of the Eisenhower Grid, an approach to task prioritization used by time-management experts.
In ambulatory care where internists provide longitudinal care to patients the Eisenhower grid can help us teach our trainees to use time as a diagnostic tool. It can help us teach our trainees to develop an approach to prioritize investigation of patient problems and decrease the ordering of unnecessary tests.
When applying the Eisenhower grid to medical problems, important means serious - e.g. something like cancer or cardiac ischemia that is likely to have long term impact on or implications for patient’s health and urgent means something that needs relatively immediate intervention to provide relief or prevent adverse outcomes. The urgent but not serious quadrant may often not apply in medicine.
Let us see how we can use this grid to approach a patient with a new complaint.
Step 1. Obtain a preliminary history of present illness.
Step 2. Populate the grid with probable diagnoses
Step 3. Obtain additional history or do a focussed physical exam to try and eliminate diagnoses from the Urgent Serious quadrant or to confirm a diagnosis from one of the other quadrants.
Step 4. If you have a probable urgent serious diagnosis that you cannot exclude, focus test ordering on that diagnosis.
Step 5. Once you are left with diagnoses in only the other 3 quadrants, you have bought yourself time. At this point, you can practice watchful waiting, empiric therapy, or less-urgent (and possibly less invasive) testing.
This is just an example and used just for illustration. Placement of various diagnoses in each quadrant may depend on various clinical factors.
One additional benefit of this approach is that our trainees will learn the importance of pattern recognition and illness scripts. These can help them use history and exam findings to exclude or decrease the likelihood of certain diagnoses. They will learn that in medicine almost nothing is certain, that they need to live with uncertainties and become comfortable with them and also help their patients become comfortable with them. They will learn to say to their patients, "I am not sure what is causing your pain. I am quite sure it is not condition X or Y and I think it is condition Z. It is safe to wait a few weeks to see if it will go away on its own, or with therapy or medication. If it does not we will do further testing."
(This post is a personal opinion and does not imply endorsement by JGIM or SGIM)
Neil Mehta, MBBS, MS
JGIM Web Editor
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