Teaching the Art of the Differential Diagnosis

[EpiEMS]

How do you teach the art of the DDx to a newbie?

I don't think I have the "art" (or the science, for that matter) 100% down, but I'd like to think I have the core (BLS-level) concept.

So, back to the question - what's the best way to teach this? Scenarios? Reviewing clinical presentations that have multiple possible etiologies (difficulty breathing) and add signs/symptoms to lean you towards certain/away from other possible causes?

 

[NomadicMedic]

When I was a paramedic student, my preceptor used to have me come up with at least 3 differentials based on the initial dispatch. Then we'd talk about it on the way. I'd have to come up with 3 on scene and then we'd talk about that after the call. It worked well for me. It got me in the mindset of thinking outside the box. (God, I hate that phrase)

 

[VentMonkey]

How do you teach the art of the DDx to a newbie?

I don't think I have the "art" (or the science, for that matter) 100% down, but I'd like to think I have the core (BLS-level) concept.

So, back to the question - what's the best way to teach this? Scenarios? Reviewing clinical presentations that have multiple possible etiologies (difficulty breathing) and add signs/symptoms to lean you towards certain/away from other possible causes?

I am not an instructor or preceptor anymore, but this course helped me a ton when I went through paramedic school. If it's available in your---or anyone's---region, I highly recommend it. Unfortunately my card is about to expire, and I still have no word from our clinical people as to when our next class is. Differential diagnosis can be a difficult concept to grasp, especially for the new provider, so again, this course takes much of "what could be wrong", and paints a fairly good clinical picture for prehospital providers.

http://www.naemt.org/education/amls/amls.aspx

 

[EpiEMS]

When I was a paramedic student, my preceptor used to have me come up with at least 3 differentials based on the initial dispatch. Then we'd talk about it on the way. I'd have to come up with 3 on scene and then we'd talk about that after the call. It worked well for me.

I'll give that a shot! I like that idea!

It got me in the mindset of thinking outside the box. (God, I hate that phrase)

The only box I like to think outside of is the box on my Type III while in a comfy chair.

I am not an instructor or preceptor anymore, but this course helped me a ton when I went through paramedic school. If it's available in your---or anyone's---region, I highly recommend it. Unfortunately my card is about to expire, and I still have no word from our clinical people as to when our next class is. Differential diagnosis can be a difficult concept to grasp, especially for the new provider, so again, this course takes much of "what could be wrong", and paints a fairly good clinical picture for prehospital providers.

http://www.naemt.org/education/amls/amls.aspx

Yeah, I've been planning to take this! I'll see when the next one is offered! I took GEMS and they covered a couple of areas where elderly folks have variant presentations, so I bet AMLS would be useful too!

 

[Brandon O]

Ugh. Hard. I have a blog post on this I never finished.

The trouble is most ways of doing it are so forced. "Give 10 differentials for every complaint" -- great, but that's not how we do it. Your differential is an evolving, dynamic panel that changes and rearranges continually during a patient encounter.

If you're running a scenario with someone (e.g. verbally), you can keep pausing at key junctures and asking how their differential looks now. Hard to do on a real call.

 

[NysEms2117]

I'm going to try and not sway this too much, however volunteering in the hospital maybe?? When I took my emt class it was downstate, I got special authorization to do my hospital clinicals at Albany med and followed around tm ts friend and a rn I knew. They were both along the lines of DEmedics learning curve. However the catch was, they only gave me 1/2 the info to start. I gave them a list of things I thought. Then they gave me the full list of info they had, and just told me. 1-10 wrong wrong wrong plausible wrong ect... Personally it was a wake up call. I can take criticism pretty well, and just hearing wrong wrong over and over was like mind blowing. However, the catch was my ts buddy also told me what he thought at different parts of the patients case. We had some of the same guesses, granted he had much more plausibles then wrongs but I guess that's what med school gets ya huh? But I think that was helpful, and I still plan on going back and doing the same thing because as with everything else *perfect* practice makes perfect.

 

[Brandon O]

I guess what I'd add to my previous is that teaching the process of forming and refining a differential is useful and important, but what it entails is operationalizing foundational knowledge about diseases, their presentation, and how to diagnose them from the history, physical, and diagnostics. Your differential is no better than that underlying knowledge. So trying to teach this can explode pretty quickly into the entire study of medicine.

 

[EpiEMS]

Your differential is no better than that underlying knowledge. So trying to teach this can explode pretty quickly into the entire study of medicine.

That's a pitfall, I agree - I do think that a nice way to go about it for me with my limited knowledge is this:

- Start with the complaint (perhaps in light of demographic and geographic information). Think of the immediate life threats (or most dangerous possible etiologies). For example, I've been called to a nursing home for an 80 year old female with acute onset difficulty breathing. Relatively quickly, we should be thinking: Pulmonary embolism, ACS, CHF, etc.

- Assess signs, symptoms, and clinical findings. Rule out what life threats you can. Treat where possible.

- Report suspicious/field impression to the receiving facility staff.

The reason I suggest focusing on life threats is that they're the main focus of EMS training - it's much easier to start there and then broaden to less urgent conditions when you have limited time and diagnostic equipment.

 

[Brandon O]

Yes, I agree. To the extent that EMS is specialization in resuscitation (and a few related areas, such as transportation, and unrelated ones, such as snacking), it's possible to become entirely expert in the diagnosis of a handful of important diagnoses -- particularly to the degree of specificity necessary to inform the decisions you'll be making (i.e. you can probably get by without knowing it's legionella if you can place a strong bet you're dealing with a septic pneumonia presentation).

 

[ExpatMedic0]

Taking a full pathophysiology class would probably be a big help. It was for me

 

[EpiEMS]

Taking a full pathophysiology class would probably be a big help. It was for me

That's definitely on my radar! Might have to be an undergraduate level class - I definitely don't have sufficient chemistry background for a graduate level one - but that's better than my current (zero pathophys classes) status!

 

[VentMonkey]

That's definitely on my radar! Might have to be an undergraduate level class - I definitely don't have sufficient chemistry background for a graduate level one - but that's better than my current (zero pathophys classes) status!

I always thought at minimum you had a bachelors, and at most you were pre-med.

 

[Carlos Danger]

That's definitely on my radar! Might have to be an undergraduate level class - I definitely don't have sufficient chemistry background for a graduate level one - but that's better than my current (zero pathophys classes) status!

Doesnt have to be grad level. You can get a really good basic handle on things from a decent undergrad phys/pathophys course. Might even be some pretty good ones online somewhere.

 

[EpiEMS]

I always thought at minimum you had a bachelors, and at most you were pre-med.

No, sir! A BA, yup, but in...economics!

 

[VentMonkey]

No, sir! A BA, yup, but in...economics!

Well, this makes even more sense.

 

[FF-EMT Diver]

Hard to explain the exact process that I use to teach my students. But I'll try.

I set up a scenario case and have them form differentials based on complaint/presentation. Some differentials will be thrown out totally and some will be moved farther back.

For instance if I give them a complaint of AMS they should at minimum have. Glucose, CVA, Aneurysm, etc.... Glucose can be ruled out by a simple check.

We make a kind of game out of it and it has really improced their assessment/diagnosis skills

Sent from my XT1565 using Tapatalk

 

[StCEMT]

I don't think there is any one way. Gotta have the foundational knowledge down. It helped having preceptors ask me what I was thinking on the way to a call and then reviewing after a call. I had to actually get out there and start working ALS calls outside of the safety net of a preceptor, run into things I was unsure of, then research them on my own. Throw in some reading on my own of whatever I felt like to supplement what I have learned. Some other thing I am probably not including. Rinse, wash, repeat.