PowerPoint Presentation

Dual Process TheoryTeaching slides based on:Schleifer JW, Centor RM, Heudebert GR, Estrada CA, Morris JL.NSTEMI or Not: A 59-Year-Old Man with Chest Pain and Troponin ElevationJ Gen Intern Med 2013; 28:58390.

System 1Intuitive, quick, reflexive, dependent on pattern recognition

DefinitionExampleDiagnosisSystem 1ReflexiveAcute diarrhea & recent antibiotics

C. difficile colitis

Teachers Guide:S1 (Ref 1)Define: intuitive, quick, reflexive, dependent on pattern recognitionExample: A patient recently treated with antibiotics who presents with diarrhea, abdominal pain, and leukocytosis likely has (then click) C. difficile colitisInvite trainees to share examples

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System 2Slow, analytical, and deliberate

DefinitionExampleDiagnosisSystem 2AnalyticalChronic diarrhea

Broad ddx

Teachers Guide:S2 (Ref 2)Define: slow, analytical, and deliberateDiscuss example: A patient with no clear risk factors presents with chronic diarrhea, abdominal pain, and leukocytosis the differential includes infection (i.e. community acquired C. diff), a noninfectious inflammatory cause (i.e. IBD), malignancy (i.e. GI tract lymphoma), malabsorption (i.e. pancreatic insufficiency)Invite trainees to share examples

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Dual Process Theory

DefinitionExampleDiagnosisSystem 1ReflexiveAcute diarrhea & recent antibioticsSystem 2AnalyticalChronic diarrhea

C. difficile colitis Broad ddx

Teachers Guide:Clinicians alternate between System 1 and System 2 thinkingknown as dual process theory of cognition Discuss when a clinician might transition from S1 to S2 reasoning (Ref 3): For example, an obese middle-aged woman presents with colicky RUQ pain; initially this presentation activates pattern recognition and consideration of acute cholecystitis, however, ultrasound rules out this diagnosis. The clinician should step back (transition to S2) and consider other diagnoses.

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HPI59yo man w/ HTN, HLD, and cerebrovascular disease p/w chest pain.

Substernal, throbbing chest pain abruptly started at rest and lasted several hours. It was associated w/ nausea, diaphoresis, dyspnea, and radiation to the left leg. The pain transiently resolved but recurred 3 hours later.

PauseWhat is your problem representation or one-liner?

What is your differential diagnosis?

Teachers guide:Request trainees describe whether their initial differential involved using S1 and/or S2 reasoningS1 reasoning for someone with chest pain includes ACS, PE, and aortic dissectionThe radiation to the left leg might cause the students to pause and activate S2 reasoning. (Only make explicit if students actually comment)Ask a trainee what they would focus on during the physical exam. This question forces the trainee to consider how a focused physical exam might impact the differential being considered.

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Physical examVitals: T 37, HR 62, BP 96/47, RR 18, O2 100% on room airGen: well appearing, no distressCV: regular rhythm, no murmurs/rubs/gallopsLungs: clear to auscultationAbdomen: soft, nt, ndExtremities: warm with no edemaNeuro: word-finding difficulties (attributed to prior stroke)

Teachers guide:Have trainee interpret physical exam and discuss next steps in managementAsk: What labs and imaging would you order, and why? Keep forcing the trainees to think aloud.

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Data

1413.510626121

1.716Hemoglobin14.5WBC12,800Neutrophils85%Lymphocytes9%Monocytes5%

UrineDrug screenNegativeProteinModerate

CK82 (ref, < 336)CK-MB1.2 (ref,