Clinical reasoning in real-world practice: a primer for medical trainees and practitioners.

Clinical reasoning is a crucial skill and defining characteristic of the medical profession, which relates to intricate cognitive and decision-making processes that are needed to solve real-world clinical problems. However, much of our current competency-based medical education systems have focused on imparting swathes of content knowledge and skills to our medical trainees, without an adequate emphasis on strengthening the cognitive schema and psychological processes that govern actual decision-making in clinical environments. Nonetheless, flawed clinical reasoning has serious repercussions on patient care, as it is associated with diagnostic errors, inappropriate investigations, and incongruent or suboptimal management plans that can result in significant morbidity and even mortality. In this article, we discuss the psychological constructs of clinical reasoning in the form of cognitive 'thought processing' models and real-world contextual or emotional influences on clinical decision-making. In addition, we propose practical strategies, including pedagogical development of a personal cognitive schema, mitigating strategies to combat cognitive bias and flawed reasoning, and emotional regulation and self-care techniques, which can be adopted in medical training to optimize physicians' clinical reasoning in real-world practice that effectively translates learnt knowledge and skill sets into good decisions and outcomes.

DUETS for Light's in separating exudate from transudate.

BACKGROUND: Fifty years since its inception, Light's criteria have aided in classifying pleural effusions (PEs) as exudates if 1 or more criteria are met. Thoracic ultrasound (US) emerges as a non-invasive technique for point of care use especially if pleural procedures are contemplated. OBJECTIVE: We aimed to develop a score based on radiological and US features that could separate exudates from transudates without serum and pleural fluid biochemical tests necessary for Light's criteria. METHODS: A prospective review of consecutive patients with PE who underwent thoracocentesis was performed. CXRs were evaluated for laterality followed by US for echogenicity, pleural nodularity, thickening and septations. PE was classified as exudate or transudate according to Light's criteria and corroborated with albumin gradient. A score combining radiological and US features was developed. RESULTS: We recruited 201 patients with PE requiring thoracocentesis. Mean age was 64 years, 51% were females, 164 (81.6%) were exudates, and 37 (18.4%) were transudates. Assigning 1-point for Diaphragmatic nodularity, Unilateral, Echogenicity, Pleural Thickening and Septations, DUETS ranged from 1 to 5. DUETS ≥2 indicated high likelihood for exudate (PPV 98.8%, NPV 100%) with 1% misclassification versus 6.9% using Light's criteria (p < 0.001). CONCLUSION: DUETS separated exudates from transudates with good accuracy, and could obviate paired serum and pleural fluid tests necessary for Light's criteria computation. Our study reflected real world practice where DUETS performed better than Light's criteria for PE that arose from more than one disease processes, and in the evaluation of patients with PE who have received diuretics.

A 67-Year-Old Man With Psoriatic Arthritis and New-Onset Dyspnea.

A 67-year-old retired air force officer presented with a 6-month history of nonproductive cough, progressive exertional dyspnea, and weight loss. He was unable to walk beyond 100 m compared with his baseline of unlimited walking distance. He denied fever, hemoptysis, myalgia, or chest pain. He had a 30-year history of chronic plaque psoriasis with arthritis, which was managed by his dermatologist with emollients and vitamin D analogues. Joint involvement had previously been controlled with methotrexate, which was discontinued 15 years ago after resolution of his symptoms. He developed a polyarthritis flare a year ago, and adalimumab was initiated with good response.

Bedside pleural procedures by pulmonologists and non-pulmonologists: a 3-year safety audit.

BACKGROUND AND OBJECTIVE: Pleural procedures such as tube thoracostomy and chest aspirations are commonly performed and carry potential risks of visceral organ injury, pneumothorax and bleeding. In this context limited information exists on the complication rates when non-pulmonologists perform ultrasound-guided bedside pleural procedures. Bedside pleural procedures in our university hospital were audited to compare complication rates between pulmonologists and non-pulmonologists. METHODS: A combined safety approach using standardized training, pleural safety checklists and ultrasound-guidance was initially implemented in a ∼1000-bed academic medical centre. A prospective audit, over approximately 3.5 years, of all bedside pleural procedures excluding procedures done in operating theatres and radiological suites was then performed. RESULTS: Overall, 529 procedures (295 by pulmonologists; 234 by non-pulmonologists) for 443 patients were assessed. There were 16 (3.0%) procedure-related complications, all in separate patients. These included five iatrogenic pneumothoraces, four dry taps, four malpositioned chest tubes, two significant chest wall bleeds and one iatrogenic hemothorax. There were no differences in complication rates between pulmonologists and non-pulmonologists. Presence of chronic obstructive pulmonary disease (COPD) independently increased the risk of complications by nearly sevenfold. CONCLUSIONS: Results from this study support pleural procedural practice by both pulmonologists and non-pulmonologists in an academic medical centre setting. This is possible with a standard training program, pleural safety checklists and relatively high utilization rates of ultrasound guidance for pleural effusions. Nonetheless, additional vigilance is needed when patients with COPD undergo pleural procedures.