Rabih Geha, Denise M. Connor, Jeff Kohlwes, Reza Manesh
An illness script is an organized mental summary of a provider’s knowledge of a disease (1-3). It represents a clinician's knowledge about a particular disease, and may be as short as a 3x5 pocket card description for a rare disease, or as long as a book chapter for a commonly encountered illness. Classically, the components of a thorough illness script fall into three main categories: “the predisposing conditions, the pathophysiological insult, and the clinical consequences (4).” Within these categories, illness scripts often include a disease's pathophysiology, epidemiology, time course, salient symptoms and signs, diagnostics, and treatment. For example, a provider’s illness script for community acquired pneumonia (CAP) may include:
With experience, providers hone their illness scripts in three important ways (5):
This iterative process, continued throughout a clinician’s career, adds depth, precision and differentiating power to the foundational scripts developed during training (5). Diseases encountered less frequently will have less robust scripts.
Attached Illustrative Teaching Case: [Based on JGIM article available free online at PubMed Central]
In the case of A 22-Year-Old Woman with Abdominal Pain an approach to illness scripts for rarer diseases is explored (6). The clinician, analyzing the case using System 1, or pattern recognition, quickly determines that the problem representation of recurrent, acute abdominal pain with non-diagnostic imaging in a young woman does not adequately match his illness script for a common disease. This realization prompts the transition to a systematic and deliberate mode of reasoning, System 2. The clinician notes that his illness script for acute intermittent porphyria (AIP) is not comprehensive because it is a disease that he has rarely encountered. Yet, his limited script is still sufficient to prompt him to think of the disease in the context of dark urine and the introduction of a new medication. The clinician appropriately entertains the diagnosis, and then researches the medication list, uncovering a drug that can precipitate an acute pain crisis, and ultimately clinching the diagnosis of AIP.
While also highlighting the importance of problem representation and the two modes of clinical reasoning, this case emphasizes another fundamental feature of diagnostic excellence: the ability of experts to select, encode and retain key features of rare diseases in their more limited illness scripts, prompting them to consider an unusual diagnosis when appropriate (5, 7).
The slides for this case include an embedded teaching guide and provide a didactic approach for teachers interested in developing their trainees’ understanding of the clinical reasoning process. They can be viewed here or downloaded from slideshare.
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