NR 603 Week 8 Synthesis Paper Example

Synthesis Paper: The Habit I Had to Lose Was Naming the Problem Before the History Was Finished, Shown in Three Patients Across the Lifespan and the Cost Each Time

Student Name

College of Nursing, Chamberlain University

NR 603: Advanced Clinical Diagnosis and Practice across the Lifespan Practicum

Instructor Name

Month Day, Year

Synthesis Paper: The Habit I Had to Lose Was Naming the Problem Before the History Was Finished, Shown in Three Patients Across the Lifespan and the Cost Each Time

The Thesis

The habit I had to lose this term was reaching for a diagnosis before the history was finished. It was efficient, it was often right and it was most dangerous in exactly the patients where it was wrong. Three cases, an infant, an adult and an older adult, show where it happened and what it cost.

Case 1: An Infant, "Just Fussy"

A 9-week-old was brought in by a parent because the baby had been "fussy and not feeding well" for a day. By the second sentence I had decided on colic. The baby was feeding a little less, crying more in the evenings and had no cough or diarrhea. My preceptor asked whether I had taken a temperature myself. The rectal temperature was 38.3 °C. In an infant under 3 months, a fever without a clear source calls for urine and blood tests, because serious bacterial infection, often a urinary infection, may show no other sign. The urine culture grew bacteria. The baby was treated for a urinary tract infection.

What age did: in a 9-week-old, fussiness and poor feeding are among the few ways a serious infection shows itself. In a 9-month-old, the same words would more often mean teething or a cold. The cost of my early label would have been a missed infection in a baby too young to show it any other way.

Case 2: An Adult, "Just Tired"

R.M., 58, was tired, breathless on stairs and had lost 4 kilograms. At the first visit, before I had a blood count, I was ready to call it stress and a vegetarian diet. Holding three explanations open, ranked by consequence, sent R.M. for tests that showed iron deficiency anemia with a ferritin of 8, and then for endoscopy. The colonoscopy found a 2-centimeter polyp in the ascending colon with high-grade dysplasia, removed in the same session; the upper endoscopy found a small ulcer in the stomach consistent with ibuprofen use. Either could have caused the blood loss. The polyp, left for a few more years, could have become a cancer.

What age did: at 58, unexplained iron deficiency means looking for blood loss in the gut, and the cost of an early label of "diet" would have been a missed precancerous lesion (Ko et al., 2020).

Case 3: An Older Adult, "Just Dizzy"

A 72-year-old described being dizzy three weeks after starting tamsulosin. My first thought, a blood pressure drop from the new medicine, turned out right: the standing pressure fell by 28 points. But I nearly stopped there. The question I had learned to ask, about double vision, speech and weakness, was answered no, which matters, because at 72 a brainstem stroke can present as dizziness. The early label would have been right this time, but it would have been right without my having checked the dangerous alternative.

What age did: at 72, the list for dizziness includes heart rhythm problems and stroke, which barely feature at 24.

The Counterargument

Experienced clinicians use pattern recognition constantly, and it is usually right. Norman et al. (2017) conclude that missing knowledge, more than hasty thinking, lies behind most reasoning errors, and that slowing down does not reliably prevent them. I take that seriously. My answer is narrower: I do not need to slow down every diagnosis. I need to slow down when the patient is at an age where the dangerous alternative is common and the early label is comfortable. In each of the three cases, the comfortable label was the benign one.

What the Three Cases Have in Common

In each case, the early label came from the most common cause of the symptom in general, and in each case, the patient's age made a less common but more dangerous cause more likely than usual. The infant's age made a hidden infection more likely; R.M.'s age made a colon lesion more likely; the older adult's age made a stroke more likely. The habit was not wrong because pattern recognition is bad; it was wrong because it used the general pattern instead of the pattern for that age.

What Did Not Change

I have not stopped forming early impressions; I do not think I could or should. What changed is that I treat the first impression as a hypothesis to test against the most serious alternative for that age, not as the answer. In most visits this takes a minute. In the three cases above, it changed what happened.

What Changed in Practice

I now say the early label to myself and then ask one question: what would I miss if this is wrong, at this patient's age? For the infant, a urinary infection. For R.M., a colon lesion. For the 72-year-old, a stroke. If the answer is serious, I check before I commit.

Croskerry (2003) names premature closure as one of the commonest cognitive errors; my version of the strategy that paper recommends is that single question.

What This Means for Teaching

If I precept students later, I will ask them for their first impression early and then ask what they would miss if it were wrong at that patient's age. The question is short, it can be asked aloud in clinic and it does not slow down the visits where the first impression is right.

Where the Habit Came From

Eight years in an emergency department taught me to make a working diagnosis quickly, because the next patient was waiting and the department had a team behind me to catch errors. In primary care, I see patients alone, often only once in several months, and nobody downstream is set up to catch a wrong first label. The habit made sense where I learned it; it needed changing for where I work now.

Implications I Could Check

In my next practicum term, I will record, for every new undifferentiated complaint, my first label and my final diagnosis. After eight weeks I will count how often they differed, and in which age groups. If they differ most often at the extremes of age, the habit is still costing something where it matters most.

Limits

Three cases from one term, chosen because they illustrate the thesis. Cases where my early label was right and checking added nothing are not shown, and there were many.

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

Ko, C. W., Siddique, S. M., Patel, A., Harris, A., Sultan, S., Altayar, O., & Falck-Ytter, Y. (2020). AGA clinical practice guidelines on the gastrointestinal evaluation of iron deficiency anemia. Gastroenterology, 159(3), 1085-1094. https://doi.org/10.1053/j.gastro.2020.06.046

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