Click here for a larger photo if you can't read my lousy handwriting.
That moment when you are watching a rhythm strip without thinking about what to look for, but looking for it anyway. Then, when a nurse asks you what you're looking for, you can answer without searching for the answer, because you've been answering the same question for yourself. In other words, the awareness of problem solving is eliminated, and you are going through an algorithm without thinking about going through it.
- Clinical appearance: stable or unstable?
- Telemetry interpretation: rate, rhythm, wide or narrow?
- Differential diagnosis: toxic/metabolic, ischemic, anatomic, EP
- End-organ effects: mentation, urine output, blood pressure
- Interventions: AV blockade, cardioversion, O2
See how an algorithm, once learned, becames a series of parallel, mutually occurring feedback loops of reasoning. Or circular. Or big Medusa's web of questions/answers/possible solutions, each of which is ore or less ideal depending on the patient's changing status. So when the nurse says, "I guess it won't help to cardiovert if she keeps going in and out of flutter," I say, silently acknowledging that her statement is true:
"Also, she's not really falling into the unstable category right now." Answering her question (cardioversion less likely to help with paroxysmal SVT) and my own (unstable? no, stable).
I don't know why this fascinates me, except that I cannot for the life of me remember when I learned to think like this.
1. Although I've never been a fan of Groupthink, I do think it is helpful to have colleagues with whom I can discuss cases. This was the biggest safety valve I had during residency--having other residents around to talk about patients. Granted, we were all booger-nosed newbies, but we were grounded enough to look things up and ask for help when we felt we were in over our heads. Unfortunately, in the real world I don't have immediate access to casual colleagues to run cases. My hospital is small enough that only one hospitalist covers each shift. Certainly, I can consult cardiologists, nephrologists, pulmonologists, neurologists, but even the most generous consultant I know doesn't want to get dragged into every single case, and professional liability makes them cautious about providing curbside opinions. I'd like to see a culture shift towards informal collaborative problem-solving in medicine.
2. If, in the most basic form, diagnostic decision-making is a combination of algorithmic mastery and gut instinct, then both elements require a large pool of experiences to refine their accuracy. Translation: Doctors should see a lot of patients with a lot of different problems in order to become better diagnosticians. This must happen as part of medical education, which is one of the reasons I have written about my reservations about further reductions in resident work-hours.
Pattern recognition, Croskerry told me, "reflects an immediacy of perception." It occur within seconds, largely wihtout any conscious analysis; it draws most heavily on the doctor's visual appraisal of the patient. And it does not occur by a linear, step-by-step combining of cues. The mind acts like a magnet, pulling in the cues from all directions.