Clinical decision making in real time

When presenting a complicated case, educators in our department want to teach learners that how to arrive at a conclusion can be more instructive than guessing at the correct diagnosis. Of course getting it right matters for the patient more, but the educational opportunity is more about the rigorous interrogation of facts and the questions that follow.

This was in evidence at a recent Grand Rounds delivered by Gurpreet Dhaliwal, MD, a clinician-educator at the University of California, San Francisco. The audience watched as Dhaliwal absorbed bits of information about a case and talked through his suspicions at each stage. He described what tests he might order next, what data would sit in his backpocket until other data emerged, revisions to earlier suspicions, doors he could confidently close or paths to ignore. All in real time.

Chief Resident Tyler Bullis, MD, organized and delivered the case of a 22-year-old woman who presented with a history of migraine with aura and recent abdominal pain and vomiting. At each stage of Bullis’s case presentation, from vitals to past medical history to blood draws to CT scans, he would pause to allow Dhaliwal to give his impressions and share his thinking.

If you have not yet watched the presentation, we recommend that you not scroll down to the photos just yet, but that you first watch here (HawkID login required). This affords you the opportunity of going on the same journey of exploration that Dhaliwal, Bullis, and the audience members also traveled.

Although the diagnosis is relatively unusual, once Dhaliwal reached his conclusion (which, for the record, was on his list of possibilities from the start), he was clear about why this was “a great case” for this exercise. “Not because of its final, unusual diagnosis, but because of its decision nodes.” Deciding whether or not alcoholism-induced cirrhosis was at play proved to be a critical factor. “That’s such a big branch point,” he said, that once the liver biopsy results allowed for ruling it out, it freed him to consider the true culprit in the patient’s severe abdominal pain.

“Everyone should take away their own lesson,” Dhaliwal concluded. “The end diagnosis is interesting, but hopefully there is something upstream, some part that’s sort of an upgrade for you.”

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