A must read post by Javier Benetiz (G+ / Twitter) featured on Academic Life in Emergency Medicine recently. It cast the spotlight on Peter Rosen’s classic specialty-defining 1979 essay “The biology of emergency medicine”. I’d like to focus your attention on on one small facet that deserves emphasis:
“The hardest thing to teach residents, according to Dr. Rosen, is to “assume the worst even if statistically improbable”. I believe that Dr. Amal Mattu (@amalmattu) refers to this as a “healthy paranoia”. This means that we still need to rule out life threatening diagnoses for seemingly non-emergent patients.”
It is only natural for the beginner in emergency medicine to feel reassured that a patient looks well enough, even if there are potentially life-threatening causes for the patient’s presentation. After all, common things occur commonly. We all want to be able to reassure our patients that they are going to be fine. We don’t like jabbing them with needles or exposing their glands to radiation. The rare but deadly diagnoses that demand exclusion might have never been encountered by the novice. Indeed, they might only be faded medical school memories. It is also more work and more effort — both physical and cognitive — to follow through on these dangerous differentials. As human beings we all naturally incline towards the path of least resistance.
So, how can we help our junior colleagues consider not only common diagnoses, but also those that are commonly deadly?
Listeners of Amal Mattu’s talk on Teaching in the ED will recall his ‘Hear hoof beats? Think of lions, tigers and bears!’ technique. To ensure the technique is geographically appropriate, I use the Australian Top End version: ‘Hear hoof beats? Think of Crocs, Stingers and Taipans!’.
What is this technique?
It’s a little game you can play whenever a junior colleague presents a case to you. Sure, the patient may have a common, mundane, non-life threatening disorder —a horse — but by asking your junior colleague to think of ‘crocs, stingers and taipans’ he or she has to think of three dangerous mimics that are in the differential. It only takes seconds, and with repeated iterations the learner starts to unconsciously and effortlessly bring dangerous differentials to the forefront of their thinking. In this way, you can help juniors overcome availability bias. Together, you can then explore the reasons why you can relax and not worry about being bitten or stung by a Top End beastie… Or, as is often the case, why you can’t.
‘Hear hoof beats? Think of Crocs, Stingers and Taipans!’ encourages us all to develop the ‘healthy paranoia’ that is essential for emergency medicine excellence.
But thinking of badness is one thing, learning what to do about it is another…