Any internal medicine doctor worth their salt will argue that the most important procedure they do everyday is “thinking”. Thinking about the diagnosis, the management, the patient, and thinking itself. I chat with Dr. Aberegg—pulmonary and critical care doctor from University of Utah—as we run through his core insights from years of diagnostic detective work.
You can find his social media account and blog(s) below:
https://www.medicalevidenceblog.com/
https://x.com/phlegmfighter?lang=en
The central paper we discuss is the following:
https://link.springer.com/article/10.1007/s11606-024-09120-y
Show Notes:
[0:20] What is clinical reasoning? How should we think of it? (Clinical reasoning is responding to a 911 call and you are trying to identify the problem and pinpoint the culprit)
- “Ten rules for the doctor-detective” Marshal Goldberg 2015 (https://www.tandfonline.com/doi/pdf/10.3810/pgm.1997.02.153)
[5:50] The wisdom in looking for a unified causal picture for a patient’s chief concern
- How did Dr. Aberegg begin thinking about Ockham’s razor and Hickam’s Dictum?
- Hickam’s Dictum enters modern diagnostic discourse in the literature (Sanjay Saint et al 2004)
- https://www.tandfonline.com/doi/pdf/10.3810/pgm.1997.02.153
- What many people think are different disorders are actually:
- Incidentalomas
- Superimposed chronic condition
- Consequence of another disorder that is causally linked
- A True Hickam’s Dictum
[11:30] The philosophical underpinnings behind looking for a unified causal explanation in critical care and internal medicine (Riechenbach’s common cause principle)
[18:20] How the intuition of looking for a unifying diagnosis helped solve a case of a young man with pulmonary infiltrates and interstitial lung disease
[21:10] Learners make diagnostic errors: Is it primarily because of knowledge deficits or cognitive biases?
- Pat Croskerry MD PHD who is a world renowned expert on cognitive biases and how it relates to accurate diagnosis (https://www.nejm.org/do/10.1056/NEJMdo002218/full/)
- Knowledge deficit hierarchy
- Knowledge Deficit Misdemeanour (not knowing arcane knowledge)
- Knowledge Deficit Felony (not knowing patient factor that can be found on physical exam and history)
[35:45] What is a differential diagnosis really and why does it matter?
- It highlights the knowledge deficits that could lead us astray in the clinical reasoning process
- The physicians’ prayer (https://pmc.ncbi.nlm.nih.gov/articles/PMC1114481/)
[41:00] Dr. Aberegg’s Problem-Prove-Cause-Cure Framework for checking your diagnostic reasoning in a time crunch
[57:50] Using the model in a clinical story
