Medical Decision-Making

Keith Bradley, MD

Director

Research Associates Program at St. Vincent’s

National Alliance of RA Programs

Three (3) Modes of Diagnosis

• Pattern Recognition (“Augenblick”)

• Branching

• Matching

Augenblick

“blink of an eye”

See it; know it

ABC’s

• A = asymmetric

• B = border irregular

• C = color black or variable

• D = diameter > 1/4”

Branching

Branching

e.g., Chest Pain

Branching

e.g., Chest Pain

• “expert”

Branching

e.g., Chest Pain

• “expert”

• “blinders”

Branching

e.g., Chest Pain

• “expert”

• “blinders”

potential for error

Branching

e.g., Chest Pain

• “expert”

• “blinders”

potential for error

• “practice”

Matching

Matching

• ALL possible diagnoses on x-axis

Matching

• ALL possible diagnoses on x-axis

• Each possible – symptom

– sign on y-axis

– investigation result

Matching

• ALL possible diagnoses on x-axis

• Each possible sx, px, tx on y-axis

• = Excel spreadsheet

Matching

• ALL possible diagnoses on x-axis

• Each possible diagnoses on y-axis

• = Excel spreadsheet

• Lawrence Weed, MD / “couplers”

Different Types of Problems Different Types of Responses

Non-Traumatic Unconsciousness

Non-Traumatic Unconsciousness

• Airway

Non-Traumatic Unconsciousness

• Airway

• Breathing

Non-Traumatic Unconsciousness

• Airway

• Breathing

• Circulation

Non-Traumatic Unconsciousness

• Airway

• Breathing

• Circulation

• Defibrillate

Types of Problems Types of Responses

Problem Response

Acute Rapid, simple,

memorized

Fever, Ear Pain in a 3 year old

Fever, Ear Pain

Fever, Ear Pain

Fever, Ear Pain

• Dx = acute otitis media

• Tx = depending on timing: nothing or Abs

Types of Problems Types of Responses

Problem Response

Acute Rapid, simple,

memorized

Routine Routine, stylized

“My leg is swollen”

“My leg is swollen”

• What would Dr. House do?

“My leg is swollen”

• What would Dr. House do?

• DDx

“My leg is swollen”

• What would House do?

• DDx

• Key Question … never forget to ask = ?

“My leg is swollen”

• What would House do?

• DDx

• Key Question … never forget to ask

• Be the star!

“My leg is swollen”

• What would House do?

• DDx

• Key Question … never forget to ask

• Be the star! – thick smear … draw blood at night

“My leg is swollen”

• Dx = filiariasis

“My leg is swollen”

• Dx = filiariasis

• Tx = anti-helminths or …

“My leg is swollen”

• Dx = filiariasis• Tx = anti-helminths or …

– The parasites responsible for filariasis have a population of symbiotic bacteria, Wolbachia, that live inside the worm.

– When the symbiotic bacteria are killed by the antibiotic, the worms themselves also die.

• Doxycycline might be effective– Clinical trials in June 2005 by the Liverpool School

of Tropical Medicine reported that an 8 week course almost completely eliminated microfilariaemia.[4][5]

Types of Problems Types of Responses

Problem Response

Acute Rapid, simple,

memorized

Routine Routine, stylized

Unique Unique

MVC, Multiple Trauma

Types of Problems Types of Responses

Problem Response

Acute Rapid, simple, memorized

Routine Routine, stylized

Unique Unique

Complex Complex