NR 511 Week 8 Practice Reflection on Reasoning Example

Practice Reflection: I Came Into NR 511 Writing the Diagnosis First and the Reasons Second, and Two Case Papers From This Term Show the Order Changing

Student Name

College of Nursing, Chamberlain University

NR 511: Differential Diagnosis and Primary Care Practicum

Instructor Name

Month Day, Year

Practice Reflection: I Came Into NR 511 Writing the Diagnosis First and the Reasons Second, and Two Case Papers From This Term Show the Order Changing

The Habit I Arrived With

For eleven years I worked on a cardiac step-down unit, where my job at handover was to give the next nurse a clean picture: this is the patient, this is what is wrong, this is what to watch. A good handover sounds settled. Uncertainty, said aloud, sounded like I had not done my job. I did not notice how completely that habit shaped my writing until the first weeks of this course, when I realized I was writing the diagnosis in my first sentence and then collecting reasons for it.

The pattern has a name. Croskerry (2003) lists premature closure among the cognitive errors of diagnosis: the decision is made, and the thinking stops, before the diagnosis has been confirmed, and in a review of 100 diagnostic errors in internal medicine, Graber et al. (2005) found that premature closure, the failure to keep considering reasonable alternatives after an initial diagnosis, was the single most common cognitive cause. Reading that in Week 2 was uncomfortable. It described my handovers exactly, but it also described the way I had just written my first case.

Earlier Work as Evidence

Week 4, first draft. The case was a 71-year-old man with a hot, swollen knee ten days after hernia surgery, taking hydrochlorothiazide and with a raised uric acid. My first draft, which I still have, began: "This patient is experiencing an acute gout flare precipitated by thiazide diuretic use and recent surgery." Every paragraph after it defended that sentence. The meniscal calcification on his radiograph appeared in one line near the end as an incidental finding, and septic arthritis appeared nowhere. My instructor's comment was short: "What would make you wrong?" I had no answer in the paper.

Week 4, final version. I rewrote it with two readings in parallel, gout and calcium pyrophosphate disease, and dealt with infection first because it was the one that could not be missed. I did not know which reading would win until the crystal result came back, and it was not the one I had written in my first sentence. The lesson I took was not that I had been wrong about gout. It was that my draft had made it impossible to find out.

Week 7. The shoulder pain case was a test of whether the change would hold when I was not being prompted. A retired roofer had been treated for six weeks for rotator cuff disease and came back with arm pain, hand weakness and a drooping eyelid. This time, before I wrote any diagnosis, I wrote a list of every finding and asked which candidates explained all of them. Only one did. I also wrote out the case for two unrelated problems and gave carotid dissection its own paragraph, because it was dangerous whether or not I believed it. The final ranking put an apical lung tumor first, but the paper shows how it got there.

What Changed, as a Practice

What changed is not my confidence, which is about the same. What changed is the order in which I write. I now do three things before I name a working diagnosis. I list the findings, including the ones that do not fit anything yet. I write the candidates that the findings raise, each next to the finding that raised it. And I write the one result that would separate the top two. Only then do I write the sentence that begins "The working diagnosis is." This is a habit I can check in my own drafts: if the diagnosis appears before the list, I have slipped back.

I have also started asking myself whether I know enough about each candidate to weigh it fairly. Norman et al. (2017) reviewed the evidence on reasoning errors and concluded that teaching clinicians to recognize their biases does not reliably reduce errors, while strategies that reorganize knowledge have small but consistent benefits. That changed how I studied in the second half of the term. For the facial palsy case in Week 5, I did not only remind myself to consider alternatives. I learned why forehead weakness separates a peripheral from a central lesion, which is what let me move stroke down with a reason rather than a hope.

What Is Still Hard

Holding a list open is easier on paper than in a room. The written cases gave me time; a clinic day does not. In clinical this term, with a patient in front of me and a preceptor waiting, I still feel the pull to give a settled answer. Twice I presented a case to my preceptor with one diagnosis and no alternatives, and both times she asked me for the list and I produced it only after being asked. I also find it hard to decide when a list should close, and I suspect that is the next skill rather than a side issue. In the chronic cough case in Week 3, I kept four candidates alive longer than was useful, and the plan I wrote tested too many things at once until I cut it back to one change at a time. Keeping the list open is not the same as never deciding.

Commitments for the First Year of Practice

First, for every new problem visit, I will write at least two alternatives in the assessment before I write the plan, and I will ask a colleague to audit ten of my notes at three months for this.

Second, when I present to a collaborating physician or senior nurse practitioner, I will give the list first and my choice second, which is the reverse of how I was trained to give report.

Third, when a treatment is not working, I will write down the original diagnosis and ask whether the response still fits it before I change the treatment, as the Week 6 note did for a patient whose diabetes label no longer fit.

Fourth, I will study each month's missed or delayed diagnoses from my own practice by the knowledge they required, not only by the bias involved, and keep a short log of what I learned. I will review this reflection at the end of my first year to see which of these commitments I actually kept.

References

Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8), 775-780. https://doi.org/10.1097/00001888-200308000-00003

Graber, M. L., Franklin, N., & Gordon, R. (2005). Diagnostic error in internal medicine. Archives of Internal Medicine, 165(13), 1493-1499. https://doi.org/10.1001/archinte.165.13.1493

Norman, G. R., Monteiro, S. D., Sherbino, J., Ilgen, J. S., Schmidt, H. G., & Mamede, S. (2017). The causes of errors in clinical reasoning: Cognitive biases, knowledge deficits, and dual process thinking. Academic Medicine, 92(1), 23-30. https://doi.org/10.1097/ACM.0000000000001421