Lessons in clinical reasoning – pitfalls, myths, and pearls: how search satisfying can keep eyes crossed
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Margaret E. Tashjian
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Jessica Parker
Abstract
Objectives
Missed opportunities for diagnostic excellence are common and can lead to delayed diagnoses and initiation of treatment. Medical teams incorporate many elements into the diagnostic process, including patient factors, medical knowledge, data gathering, care environment, subspecialized personnel, and hospital processes. A case-based discussion describes how search satisfying – the tendency to stop searching once something has been found – and authority gradients can lead to delays in diagnosis.
Case presentation
A 2-year-old girl repeatedly presents to the emergency department with vomiting and periorbital swelling progressing to esotropia, initially found to have normal short-sequence MR brain imaging. After nonspecific labs and reassuring initial imaging, ophthalmologic consultation obtained during the child’s third emergency department visit proposed plausible diagnoses of benign post-viral esotropia or decompensated esotropia. When her exam worsened at ophthalmology clinic follow up, she was referred back to the emergency department for complete MR brain and orbit imaging leading to a diagnosis of bilateral orbital myositis.
Conclusions
Examining the diagnostic process through integrated commentary, this case emphasizes the importance of recognizing limitations of short-sequencing advanced imaging and continuing the diagnostic pursuit in collaboration with consultants. A fishbone diagram visually demonstrates the factors that lead to a missed opportunity for diagnostic excellence. The case concludes with clinical teaching points in addition to a pitfall, myth, and pearl specific to search satisfying and authority gradients.
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Research ethics: Not applicable.
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Informed consent: Not applicable.
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Author contributions: The authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Use of Large Language Models, AI and Machine Learning Tools: None declared.
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Conflict of interest: The authors state no conflict of interest.
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Research funding: None declared.
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Data availability: Not applicable.
References
1. Harel, S, Mallon, M, Langston, J, Blutstein, R, Kassutto, Z, Gaughan, J. Factors contributing to nonvisualization of the appendix on ultrasound in children with suspected appendicitis. Pediatr Emerg Care 2022;38:678–82. https://doi.org/10.1097/pec.0000000000002394.Search in Google Scholar
2. Cohen, AR. Brain tumors in children. N Engl J Med 2022;386:1922–31. https://doi.org/10.1056/nejmra2116344.Search in Google Scholar
3. Alzimami, K. Assessment of radiation doses to paediatric patients in computed tomography procedures. Pol J Radiol 2014;79:344–8. https://doi.org/10.12659/pjr.890806.Search in Google Scholar
4. McNab, AA. Orbital myositis: a comprehensive review and reclassification. Ophthal Plast Reconstr Surg 2020;36:109–17. https://doi.org/10.1097/iop.0000000000001429.Search in Google Scholar PubMed
5. Chédeville, G, Scuccimarri, R. Orbital myositis: a report of 3 pediatric cases. Pediatr Rheumatol 2012;10:S1–2.10.1186/1546-0096-10-S1-A92Search in Google Scholar
6. Okutan, V, Yavuz, ST, Mutlu, FM, Akin, R. Benign recurrent abducens (sixth) nerve palsy. J Pediatr Ophthalmol Strabismus 2009;46:47–9. https://doi.org/10.3928/01913913-20090101-18.Search in Google Scholar PubMed
7. Werner, DB, Savino, PJ, Schatz, NJ. Benign recurrent sixth nerve palsies in childhood secondary to immunization or viral illness. Arch Ophthalmol 1983;101:607–8. https://doi.org/10.1001/archopht.1983.01040010607016.Search in Google Scholar PubMed
8. Sturm, V, Schöffler, C. Long-term follow-up of children with benign abducens nerve palsy. Eye (Lond). 2010;24:74–8. https://doi.org/10.1038/eye.2009.22.Search in Google Scholar PubMed
9. Lindberg, DM, Stence, NV, Grubenhoff, JA, Lewis, T, Mirsky, DM, Miller, AL, et al.. Feasibility and accuracy of fast MRI versus CT for traumatic brain injury in young children. Pediatrics 2019;144:e20190419. https://doi.org/10.1542/peds.2019-0419.Search in Google Scholar PubMed
10. Yue, EL, Meckler, GD, Fleischman, RJ, Selden, NR, Bardo, DM, Chu, O, et al.. Test characteristics of quick brain MRI for shunt evaluation in children: an alternative modality to avoid radiation. J Neurosurg Pediatr 2015;15:420–6. https://doi.org/10.3171/2014.9.peds14207.Search in Google Scholar
11. Rozovsky, K, Ventureyra, EC, Miller, E. Fast-brain MRI in children is quick, without sedation, and radiation-free, but beware of limitations. J Clin Neurosci 2013;20:400–5. https://doi.org/10.1016/j.jocn.2012.02.048.Search in Google Scholar PubMed
12. Croskerry, P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78:775–80. https://doi.org/10.1097/00001888-200308000-00003.Search in Google Scholar PubMed
13. Croskerry, P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med 2002;9:1184–204. https://doi.org/10.1197/aemj.9.11.1184.Search in Google Scholar
14. Busby, LP, Courtier, JL, Glastonbury, CM. Bias in radiology: the how and why of misses and misinterpretations. Radiographics 2018;38:236–47. https://doi.org/10.1148/rg.2018170107.Search in Google Scholar PubMed PubMed Central
15. Adamo, SH, Gereke, BJ, Shomstein, S, Schmidt, J. From “satisfaction of search” to “subsequent search misses”: a review of multiple-target search errors across radiology and cognitive science. Cogn Res Princ Implic 2021;6:59. https://doi.org/10.1186/s41235-021-00318-w.Search in Google Scholar PubMed PubMed Central
16. Cosby, KS, Croskerry, P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med 2004;11:1341–5. https://doi.org/10.1197/j.aem.2004.07.005.Search in Google Scholar PubMed
17. Green, B, Oeppen, RS, Smith, DW, Brennan, PA. Challenging hierarchy in healthcare teams – ways to flatten gradients to improve teamwork and patient care. Br J Oral Maxillofac Surg 2017;55:449–53. https://doi.org/10.1016/j.bjoms.2017.02.010.Search in Google Scholar PubMed
18. Holmstrom, SE, Varma, S, Augustine, E, Wilson, PM, Ramgopal, S. Longitudinal trends in pediatric return visits to US emergency departments. Pediatr Emerg Care 2022;38:1237–44. https://doi.org/10.1097/pec.0000000000002566.Search in Google Scholar PubMed
19. Lam, D, Dominguez, F, Leonard, J, Wiersma, A, Grubenhoff, JA. Use of e-triggers to identify diagnostic errors in the paediatric ED. BMJ Qual Saf 2022;31:735–43. https://doi.org/10.1136/bmjqs-2021-013683.Search in Google Scholar PubMed
20. Congdon, M, Rauch, B, Carroll, B, Costello, A, Chua, WD, Fairchild, V, et al.. Opportunities for diagnostic improvement among pediatric hospital readmissions. Hosp Pediatr 2023;13:563–71. https://doi.org/10.1542/hpeds.2023-007157.Search in Google Scholar PubMed PubMed Central
21. Aaronson, E, Jansson, P, Wittbold, K, Flavin, S, Borczuk, P. Unscheduled return visits to the emergency department with ICU admission: a trigger tool for diagnostic error. Am J Emerg Med 2020;38:1584–7. https://doi.org/10.1016/j.ajem.2019.158430.Search in Google Scholar PubMed
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