The Schizophrenic Mind of a Part-time Resuscitationist June 8, 2014 OK a quick Broome pearl tonight Scott Weingart just posted a really thought-provoking podcast on Errors of Omission vs Commission So I have put up a quick podcast to outline my thoughts about the case and the problem I see with errors involving inappropriate medicine in the ED. Please leave your thoughts on Scotts blog – or here, or both… whatever you like Casey TwitterFacebookLinkedInEmailRedditPocket Tags:decision-making, ED, education, errors Related Posts I: Vancomycin & the Nephrocidal Maniacs Clinical Case 060: Panic? Don’t Panic! .. don’t forget your towel Lessons Hard Learned: Dr Seth Trueger About The Author Casey Parker I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact 9 Comments Seth Trueger (@MDaware) Brilliantly done — I like the conception of the different gears, certainly resonates! June 8, 2014 Reply Casey Parker Thanks mate I think that as a GP generalist, working in multiple environments with vastly different acuity and disease patterns one becomes good at choosing the right gear. Still commit a lot of errors from not being aggressive enough at times – but learning to change up in the right moment – it is a balance Requires one to take a moment to contemplate your mindset before engaging the problem C June 8, 2014 Reply Brady Excellent rebuttal Casey. I love the idea of the different modes, and definitely agree with the dynamic nature of our decision-making and threshold for investigation and intervention. June 9, 2014 Reply Ron Cassano Excellent Casey; simple solution, ESP for junior docs, but good practice for all of us: 1: start with v open mind so we don’t miss anything due to our preordained prejudices 2: start in v aggressive mode AND do a good examination ( many a FACEM has missed cellulitis/abscess under a foot , esp in a dark skinned patient, and called it a PUO and over treated it) 3: within 3 minutes even a junior should be able to eliminate a life threatening illness , and gear down to appropriate mode Cheers Ron June 9, 2014 Reply Tim Leeuwenburg Thanks Casey Yeah, that Kenny Roger’s “The Gambler” refrain sums up a lot of pointy-end medicine; I’ve even heard Minh refer to it in blog posts passim… I;m interested in how we teach this. We get experience…but making mistakes. We avoid making mistakes…by experience. My feeling is that most mistakes are not those of knowledge – they are of knowing how to apply critical-decision making…how to switch gears. Worryingly, the medical system seems preset to penalise wrong decision-mkaing, hence the tendency to “play if conservative” despite patient needs. Thought? How to teach this stuff in the juniors? June 9, 2014 Reply Pik Mukherji Always risk/benefit. There are unintended consequences to aggressive workup, testing, imaging, consultation. Who is likely to benefit most? The sickest patients in whom doing nothing can reliably be predicted to have bad outcome. Who is at risk to do worse? The pts. who are the least sick, are sent for a risk of being sick (as opposed to the risk of the disease we know they have) and the asymptomatic who are pursuing preventive care. Gears is a nice way to think of it, but after your initial pt. encounter, you apply the basic rule of “the less sick the pt. is, the less aggressive you should be.”. I teach the residents that I may cancel some lab and imaging studies you want, but I won’t block an MRI of the toe in a pt. going to the ICU if it doesn’t delay other things. If the pt. is sick and you find the osteo that I missed, power to you. But in our worried well, ordering “lets make sure” tests doesn’t reassure. Know what reassures pts.? Doctors who explain why they’re ok. Worried about the medicolegal consequences of doing less? Me too. Course, there are both pt. harm AND medicolegal consequences to doing more. So I worry more about doing more. June 9, 2014 Reply Lucy Tried and failed to post a comment earlier so if I appear twice, apologies. Such an important issue. For me, as an occasional, or, if you will, part time resuscitationist, it has a lot to do with fear of having to do something that I seldom do, and perhaps getting it wrong. A process occurs in the mind which may encourage omission through fear/ lack of ability. Switching gears as you have alluded to, Casey , may help to overcome this so that one can commit to whatever procedure is needed to save our patients. For me, I try to put myself in the patient’s shoes – I know I would want my doc to do everything possible to save me. He /she would not have to beg forgiveness if it worked! And if it didn’t….well he did his best, and that is all we can ask for. June 12, 2014 Reply Casey Parker Thanks Lucy I think Cliff Reid would recommend frequent mental rehearsal as a way of preparing oneself for those cases Check out Resus.me Casey June 15, 2014 Reply Peter Weimersheimer Casey, I also agree that “mental toughness” is less of an issue then learning how to adjust our personal “modes” especially in the scenario of a crashing patient. My observation of colleagues and students over the years is that we all fall somewhere on the continuum from being open/calm/minimalists to more rapidly focused and more aggressive for non-to moderately-acute care patients. We also have varying abilities to ramp up both qualities in a sane manner with unstable patients, e.g. switching into an “action” mode for the former or not being continually overly aggressive or having too narrow a focus for the latter. Few innately have the correct mixture of calm and aggressive in managing the sick patient. Training emphasizes maximally aggressive management (“worst first”) with little focus on individual variation of providers or understanding that KNOWING when to flip the switch and HAVING THE SKILLS to function well for those critical cases is more important than always being maximal in approach. June 13, 2014 Reply Add a Comment Cancel replyYour email address will not be published. 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