Have a new kid with you today? Spend a minute with them on differential diagnosis development.
The tool I use to teach this and develop these is: SPIT
- What is most Severe? What can kill them right now? The “never miss” differentials go here.
- What is most Probable? What is most likely the issue?
- What is Interesting? What zebra do you want to chase? (Humor your imagination. You get lucky every now and then).
- What is Treatable? Is there something we can offer them?
Today’s dispatch is for a 60 y/o F with abdominal pain. How many organs are in the abdomen? There are plenty of places for illness, morbidity, and mortality to hide. Go on the ATTACK to find the cause:
- A — AAA (this is a never miss dx)
- T — Trauma (can be ruled out by history)
- T — Torsion (consider in male patients…)
- A — Appendicitis (another cant miss dx)
- C — Cholecystitis ( do you know Murphy’s sign?)
- K — Kidney issues ( referred pain by chance?)
Feel free to steal this and use this with your trainee today.
Note: The point of this exercise is to challenge them to find differentials that fit with the acronym you give them. All you need to do is give them a dispatch complaint and a random word for them to fill with the differentials. It is not intended to develop an exhaustive list of all possible differentials.
Some Background on the One Minute Preceptor:
The One Minute Preceptor (OMP) and SPIT come from the physician precepting/residency world. It is designed to frame the conversation of “what do you think is going on with this patient. Why?” without playing an elaborate game of “guess what I am thinking.”
Step 1: Make them commit to a working diagnosis. Do not overload on questions that will refine their idea just yet.
Step 2: Probe for supporting evidence. What signs and assessment findings are they using to support their working diagnosis? I like to press for 3 supporting elements. Why 3?
For me, when I’m working with a new person or a student, I want to find the gaps in their understanding and ability to put together an entire clinical picture. This avoids silly generalizations like “wheezes equal COPD” or “peripheral edema equals CHF.” When you force them to give you 3 points of supporting data, not only do they have to make sense and match their working diagnosis, they have to evaluate how those three elements relate to each other and form the working diagnosis.
Step 3: Teach General Rules. This is where you share your pearls of wisdom and your functional heuristics. Keep to the same rule that the student has to, give 3 supporting elements.
Step 4: Reinforce What They Are Doing Right. Feed back is incredibly important when developing expertise. Address more than just the “correctness” or “incorrectness” of their clinical acumen. Psychomotor skills and affective (soft) skills are equally important and do require expert feedback for effective development.
Step 5: Correct What Is Wrong. What needs to be done better, and what knowledge gaps need to be corrected? A good preceptor can do this without ripping out their guts, but you are not doing them any favors if you avoid this conversation. It does not have to be one of those “uncomfortable conversations” or “hard conversations.” Remember where you are coming from, you are coming from a good place and you are helping this person realize their goals and dreams. They cannot do that if they continue training with errors and knowledge gaps.
References:
Chinai SA, Guth T, Lovell E, Epter M. Taking Advantage of the Teachable Moment: A Review of Learner-Centered Clinical Teaching Models. West J Emerg Med. 2018 Jan;19(1):28–34. doi: 10.5811/westjem.2017.8.35277. Epub 2017 Dec 5. PMID: 29383053; PMCID: PMC5785198.
Farrell SE, Hopson LR, Wolff M, et al. What’s the evidence: a review of the one-minute preceptor model of clinical teaching and implications for teaching in the Emergency Department. J Emerg Med. 2016;51(3):278–83. doi: 10.1016/j.jemermed.2016.05.007.