Lessons in clinical reasoning ‒ pitfalls, myths, and pearls: a case of confusion, disequilibrium, and "picking at the air".

OBJECTIVES: Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. CASE PRESENTATION: A 43-year-old female was brought to the emergency department with 4-5 days of confusion, disequilibrium resulting in several falls, and hallucinations. Further investigation revealed tachycardia, diaphoresis, mydriatic pupils, incomprehensible speech and she was seen picking at the air. Given multiple recent medication changes, there was initial concern for serotonin syndrome vs. an anticholinergic toxidrome. She then developed a fever, marked leukocytosis, and worsening encephalopathy. She underwent lumbar puncture and aspiration of an identified left ankle effusion. Methicillin sensitive staph aureus (MSSA) grew from blood, joint, and cerebrospinal fluid cultures within 18 h. She improved with antibiotics and incision, drainage, and washout of her ankle by orthopedic surgery. CONCLUSIONS: Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts, this case underscores how multiple cognitive biases can cascade sequentially, skewing clinical reasoning toward erroneous conclusions and driving potentially inappropriate testing and treatment. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of structured reflection, a tool to promote metacognitive analysis, and the application of knowledge organization tools such as illness scripts to navigate these cognitive biases.

Ethical pause as a framework for high-value care of hospitalized COVID-19 patients

Caring for hospitalized patients with COVID-19 raises ethical dilemmas in which clinicians must weigh the unknown value of an intervention against the unknown risk of viral transmission. Current guidelines for delivering high-value care in the time of the COVID-19 pandemic do not directly address ethical dilemmas that arise from the unique concerns of individual patients. We propose an ?ethical pause? in which clinicians address ethical dilemmas by taking time to ask three questions that invoke the major bioethical principles of beneficence, nonmaleficence, and distributive justice: will this intervention help my patient? Could this intervention harm my patient? Could this intervention harm or help others? Using two exemplar cases, we demonstrate how the process of deliberately asking and answering structured ethical questions is a mindful problem-solving strategy that facilitates delivery of high-value care.

Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center.

BACKGROUND: The novel severe acute respiratory coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) originated in December 2019 and has now infected almost 5 million people in the United States. In the spring of 2020, private laboratories and some hospitals began antibody testing despite limited evidence-based guidance. METHODS: We conducted a retrospective chart review of patients who received SARS-CoV-2 antibody testing from May 14, 2020, to June 15, 2020, at a large academic medical center, 1 of the first in the United States to provide antibody testing capability to individual clinicians in order to identify clinician-described indications for antibody testing compared with current expert-based guidance from the Infectious Diseases Society of America (IDSA) and the Centers for Disease Control and Prevention (CDC). RESULTS: Of 444 individual antibody test results, the 2 most commonly described testing indications, apart from public health epidemiology studies (n = 223), were for patients with a now resolved COVID-19-compatible illness (n = 105) with no previous molecular testing and for asymptomatic patients believed to have had a past exposure to a person with COVID-19-compatible illness (n = 60). The rate of positive SARS-CoV-2 antibody testing among those indications consistent with current IDSA and CDC guidance was 17% compared with 5% (P < .0001) among those indications inconsistent with such guidance. Testing inconsistent with current expert-based guidance accounted for almost half of testing costs. CONCLUSIONS: Our findings demonstrate a dissociation between clinician-described indications for testing and expert-based guidance and a significantly different rate of positive testing between these 2 groups. Clinical curiosity and patient preference appear to have played a significant role in testing decisions and substantially contributed to testing costs.