Ep 201 How EM Experts Think Part 2: Data Gathering, Diagnostic and Treatment Decision Making, Test Ordering and Interpretation, Documentation, Emotional Resilience

In this Part 2 of our 2-part podcast series on How EM Experts Think with Dr. Reuben Strayer, Dr. Mike Betzner and Dr. Scott Weingart we dive deep into the nuances of practicing smarter, faster, and better in the ED. We answer questions like: How should we employ hypothetico-deductive reasoning in our daily practice of Emergency Medicine? How can we best streamline thorough data gathering for each case so that we don’t miss key data points? How do the master EM clinicians perform an efficient and targeted history and physical exam? How can the concept of heuristic cycling help you avoid outdated or faulty thinking? How can we document our clinical encounter in a way that considers a differential diagnosis that prioritizes dangerous conditions and improve our thinking around cases? How can we use the 2-10% rule for pre-test probabilities and the concept of preferred error to guide our decision making for tests and treatments in the ED? What strategies can we use to avoid anchoring bias and keep your mind open to all possibilities? What’s the role of shared decision-making when navigating diagnostic uncertainty? How does understanding the vigilance pendulum help us assess our risk tolerance better? How can post-shift decision journaling, conducting pre-mortems and meditation improve our decision making and boost our emotional resilience on shift? and many more…

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Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Rowan Helman and Anton Helman January, 2025

Cite this podcast as: Helman, A. Weingart, S. Betzner, M. Strayer, R. How EM Experts Think Part 2: Data Gathering, Diagnostic and Treatment Decision Making, Test Ordering and Interpretation, Documentation, Emotional Resilience. Emergency Medicine Cases. January, 2025. https://emergencymedicinecases.com/how-em-experts-think-part-2. Accessed January 23, 2025

Episode 200 How EM Experts Think Part 1: Strategies for Pre-Shift, Arrival Ritual, Staying Focused, Managing Interruptions, Cognitive Load & Negative Emotions, Resuscitation Mindset, Post-Resuscitation Recovery

History taking: How EM Experts Think

“We’re not as concerned only about what the patient has. We’re concerned about what the patient needs“. -Reuben Strayer

Traditional approaches to history-taking taught in medical school usually by internal medicine, often fall short in the dynamic and unpredictable environment of the ED, and fail to address the patients immediate needs. Emergency Medicine works on a hypothetico-deductive methodology, using simultaneous inductive and deductive reasoning. It involves formulating a hypothesis to make predictions, comparing predictions to observations and determining if they are consistent and finally, confirming or falsifying the hypothesis. The cardinal skill in differential diagnosis generation for EM is being able to link symptoms and signs to a list of dangerous conditions that apply to the patient in front of you. Generating a list of dangerous conditions for all common presentations to the ED at home, and them having them easily accessible via documentation templates can help hone your diagnostic skills.

Data gathering

Preparation before entering the patient’s room is critical. Effective pre-history strategies include:

• Chart Review: Review triage vital signs, nursing notes, EMS run sheets, prior visits/hospitalizations, and transfer records. This helps uncover critical discrepancies and contextualize the patient’s presentation.
• Medication and History Audit: Identify important medications and comorbidities in the patient’s chart relating to their chief complaint.
• EMS Communication: Engage directly with EMS personnel if possible, as their insights often provide invaluable context omitted from triage notes.

By setting the foundation before interaction, you can streamline the patient encounter and focus on pertinent details.

Pitfall: For patients who frequent the ED often it is important to still review prior visits/hospitalizations but be acutely aware of the potential for that information to mislead you.

History taking strategies

• Leave the obvious for last heuristic – both you and the patient will not forget to discuss their chief complaint. Start with the patient’s past medical history, medications, recent medication changes, substance use, and social context so important details are not missed. Addressing the chief complaint after understanding the broader context ensures a more directed assessment. Asking why the patient came to the ED is the obvious question that you usually already know the answer to, so don’t lead with it.
• Observe Nonverbal Cues: Pay close attention to body language and other nonverbal communication, which can provide subtle diagnostic clues.
• Elicit an Unbiased Narrative: Let the patient describe their symptoms without anchoring bias from prior visits or records. Avoid leading questions and allow them to tell their story uninterrupted.
• Listen to Your Gut: Intuition often complements clinical reasoning, especially when informed by experience.

Pearl: If you are having difficulty generating a hypothesis after initial data gathering, go back revisit other sources of information and talk with the bedside nurse who spends more time with the patient than any other health care provider in the ED.

The physical exam guided by hypothetic-deductive reasoning and differential diagnosis

Physicians’ physical exam skills have degraded over the decades as diagnostics lab and imaging tests have become more sophisticated. The physical exam remains a vital tool when executed thoughtfully and should be guided by hypothetico-deductive methodology and the differential diagnosis generated after data gathering/history taking.

• Proper Examination Setting: Ensure the patient is appropriately undressed and examined in a private space.
• Distracted Examination: Combine history-taking with physical assessment to elicit natural, undistracted reactions.
• Functional Assessment: Observing patients walking or performing simple tasks can provide insights into their functional status.
• Targeted exam maneuvers: Tailor the physical exam to the dangerous differentials in your working diagnosis. The exception to this is the patient who arrives with little data and from whom you cannot obtain a history due to altered LOA, where a more detailed physical exam is essential.
• Each physical exam maneuver should be thought of as a test: Every physical exam maneuver should be thought of as a test with likelihood ratios that can alter the probability of a particular diagnosis.
• Physical exam detail is inversely proportional to amount of subsequent lab/imaging testing: For patients who you suspect will not require further testing with labs/imaging, the physical exam should be more detailed than for the patient who will be getting imaging that is likely to make your physical exam findings irrelevant.

Functional Heuristics and Heuristic Cycling

Examples of functional heuristics which should be memorized include:

• If a patient has rhabdomyolysis, they have compartment syndrome until proven otherwise.
• All patients with unexplained severe headache require ocular pressure measurement to screen for acute angle closure glaucoma.
• Severe bradycardia/heart block is hyperkalemia until the serum potassium comes back.

Heuristic cycling: Regularly reassess the validity of your heuristics by reflecting on clinical outcomes and evidence. Practice heuristic cycling: every time you find yourself doing something by reflex, write it down. Later, ask yourself if this heuristic is still valid: when I recognize this specific pattern, can I assume this diagnosis? Keep your heuristics updated.

Dr. Weingart on Functional Heuristics

Documentation: real-time documentation and template utilization

Accurate and succinct documentation benefits both the physician and subsequent care providers. We learn more effectively when we write new information down in real time. Documentation allows us to assimilate all the information from data gathering, history and physical to come up with a reasonable differential diagnosis and treatment plan, and gives opportunity for Type 2 thinking to be integrated into our assessment. Best practices include:

• Real Time Documentation: document immediately after assessing the patient in real time; this improves accuracy and improves differential diagnosis generation.
• Minimize Auto-Imports: Avoid reliance on auto-populated notes, which often obscure critical details and diminish note quality.
• Rationale Documentation: Explicitly state reasons for not pursuing specific diagnostic pathways to demonstrate critical thinking.
• Clear Summation: Provide a concise yet comprehensive plan that outlines key findings and the rationale for management decisions.
• DDx Template Utilization: Use concise templates that contain lists of dangerous diagnoses for each presenting complaint to enhance, not replace, your clinical reasoning. Always review templates for accuracy before finalizing the documentation for a particular patient. Templates improve efficiency and minimize missing the diagnosis.

Example of Dr. Strayer’s DDx Macro Documentation Template for headache presentations

“The primary role of templates is to not to buff the chart, but to buff your brain”

Dr. Strayer on How to See Patients in the ED protocol

Test Ordering and Analysis: How EM Experts Think

Diagnostic testing in the ED must balance the need for thoroughness with the imperative to minimize unnecessary interventions. Test ordering volume will depend at least partly on one’s risk tolerance, experience, local culture, medicolegal climate, recent bad outcomes, and patient’s expectations. A structured approach includes:

• Risk Stratification: Distinguish between patients who clearly need tests, those who clearly do not, and those in the grey zone. Shared decision-making can help address diagnostic uncertainty.
• Pre-Test Planning: Anticipate how test results will influence your management before ordering. If a result will not change your course of action, reconsider the necessity of the test.
• Probability-Based Thinking: Apply these principles of diagnostic decision analysis (adapted from the landmark paper ‘Pathways through uncertainty’):
  1. Patients present with probabilities of disease, not absolutes.
  2. Diagnostic tests revise probabilities but do not confirm diagnoses outright.
  3. Interpretation should guide test ordering, not the reverse.
  4. If a test result does not change management, its utility is questionable.
• Discordant Results: When test results conflict with clinical judgment, reassess the diagnosis and management plan rather than abandoning prior reasoning.

The 2-10% rule for pretest probability and acceptable miss rate

It is reasonably well-established that the acceptable miss rate in EM for a dangerous condition is 1.8-2% based on work done by Jeff Kline on PE. If the pre-test probability of a particular dangerous condition of ≤2% the downstream harms caused by ordering the test outweighs the benefit of making the diagnosis, and the test should not be pursued.

If the pre-test probability is ≥10% then the test should be ordered.

If the pre-test probability is 2-10% (sometimes referred to as the plantiff’s gap) then shared decision making can play a key role and requires taking into consideration the patient’s risk tolerance and values. It is important to realize that, in general, patients underestimate the risk of investigations and interventions and overestimate the benefit of action.

Treatment Decisions: Preferred Error and Shared Decision-Making

Effective treatment in Emergency Medicine is as much about restraint as it is about intervention. Key strategies include:

Preferred Error Analysis: Consider which potential error (e.g., overtreatment vs. undertreatment) would result in less harm to the patient. Preferred error describes balancing the risks of action vs inaction based on the potential positive vs negative outcome of either. It begs you to consider the consequences of being wrong on both sides of the decision, and determine which course of action fails better. Factoring in how likely you are to be wrong is important in weighing the potential outcomes.

Detailed explanation of preferred error on Dr. Strayer’s emupdates

• “Don’t just do something, stand there.” (The White Rabbit in Alice in Wonderland) Sometimes the best course of action is no action at all.
• Shared Decision-Making: Engage the patient in discussions about risks and benefits, particularly when treatment options are equivocal. Again, it is important to realize that, in general, patients underestimate the risk of interventions and overestimate the benefit of action.

Post-Shift Reflection and Growth: Case Reviews, Decision Journals, The Pre-Mortem & Meditation

Continuous learning and self-reflection are vital for long-term success in EM. Be aware of the Dunning-Kruger effect, how difficulties in recognizing one’s own incompetence leads to inflated self assessment and poor performance, and the importance of staying up to date in your late career.

• Case review all your patients 4-6 weeks after their ED visit
• Teach – one of the best ways to attain knowledge on a medical topic is to teach it; take every opportunity to give a talk, write an article, guide rounds, etc.
• Decision-making Journaling: Reflect on clinical decisions after each shift, identifying areas for improvement and reinforcing successful strategies.
• Mental Rehearsal: Practice mental simulations of challenging cases procedures to enhance preparedness.
• Regular practice of HALO procedures: Regularly practice High Acuity Low Occurrence procedures with videos, 3-D printed models etc.
• Case reviews of poor outcomes: Volunteer to do case reviews for your ED group; you will learn a lot from other colleagues’ mistakes
• The Pre-mortem: like a post-mortem or a debrief after a real case, except you discuss solutions to a theoretical decision gone bad before it even happens. It involves anticipating mistakes before they happen. Ask yourself “what am I missing here” that could lead to a poor outcome?
• Meditation and Resilience: Incorporate mindfulness practices in to your daily routine to build emotional resilience and improve focus. Meditation offers a separation between stimulus and response, allowing you to become less reactive to noxious stimuli while on shift. Just 10 minutes of meditation a day can show benefits after several weeks.

Additional strategies: The EM Expert Mindset – A Female Perspective

Emotional Resilience, The Vigilance Pendulum & The Emotional Pendulum

The emotional and cognitive demands of EM, imposter syndrome and perfectionism can lead to burnout if not managed appropriately. Strategies to mitigate these challenges include:

• Case review all your patients: Reviewing patient outcomes 4-6 weeks after the ED visit builds confidence and reduces self-doubt.
• Accept and Learn from Mistakes: Acknowledge errors, take accountability, and view them as opportunities for growth.
• Vigilance Awareness: Awareness of our own Vigilance Pendulum and how it changes over time helps build emotional resilience. When a poor outcome occurs it increases our vigilance for that particular diagnosis which leads to overtesting. For example, if you miss a PE leading to a poor outcome, you will increase your D-dimer ordering and CTPA ordering). After many negative CTPAs your vigilance pendulum will swing the opposite way and swing too far until you suffer another miss. Through our career we swing back and forth on the vigilance pendulum, but over years, as you gain more experience, the magnitude of the swing diminishes as you home in on your best practice. Similarly our Emotional Pendulum swings back and forth, and it is important to embrace those highs and lows and learn from them, and realize that the swings typically diminish in size through your career.

References

Drs. Helman, Weingart, Betzner and Strayer have no conflicts of interest to declare