Recognizing déformation professionnelle in clinical reasoning

We take a deep dive into the way learners and educators make connections between clinical concepts to better understand the clinical reasoning process.

Welcome! Tell us a bit about yourself.

Hi I’m Rahul, an endocrinologist and general physician in Melbourne, Australia. In addition to clinical work I’m currently completing a PhD in inpatient diabetes and have the privilege of teaching the second-year Doctor of Medicine students, their first year in a hospital setting.

An abdominal neuroendocrine *tumour* could be one of a few different types:

If it’s an insulinoma it may present with Whipple’s *triad* of:
– Symptoms of hypoglycaemia
– Laboratory-proven hypoglycaemia
– Symptoms that improve with glucose

Or it could be a glucagonoma, it which case it may present with the characteristic *dermatitis* known as necrolytic migratory erythema

Or it could be a paraganglioma, one treatment for which is a sympathectomy, which, if performed high enough up the sympathetic chain, results in *miosis*

 See Rahul’s Twitter post for more details.

When you first saw these cards, what was your approach to creating your teaching points?

In clinical medicine it is encouraged to seek unifying diagnoses or frames. So rather than just seeking to link each of the three pairs (tumour/triad, triad/dermatitis, triad/miosis) I sought to come up with a concept that would link all four cards. Also, seeing @MElashwal97’s impressive multi-connections prior to my getting in on the game made me think that this was what one had to do!

How did you decide to make your second connection?

Once I was thinking about pancreatic tumours (insulinomas), “dermatitis” immediately made me think about the characteristic dermatitis of glucagonomas. Had I not been thinking about insulinomas, on seeing triad/dermatitis I probably would have thought of the atopic triad / atopic march and eczema / atopic dermatitis rather than the necrolytic migratory erythema of glucagonomas, so my connection was definitely sequential and dependent on the frame of thinking I was already in.

Which raises an interesting meta-point about cognitive bias. The nature of connections we make between signs, symptoms, investigation results, and diagnoses depends a lot upon the context we view them in. If a young individual with a syncopal episode after which the ambulance recorded both fingerprick hypoglycaemia and hypotension gets referred to an endocrinology clinic, they’re more likely to get fasting insulin levels and a 72-hour fast requested than if they’re referred to cardiology, where they’re more likely to initially have a Holter monitor, 24-hour ambulatory blood pressure monitoring, or exercise stress test.

Hopefully the student and young doctors playing Table Rounds can not only learn medical facts but through dissecting their thinking processes and those of others, recognise the role that cognitive biases, in particular framing, anchoring, and so-called “deformation professionnelle” biases, play in our clinical thinking and decision-making.

Was your process different for making your third connection?

Now that I was in the frame of neuroendocrine tumours I chose this is the meta-concept and from there, the only two links between tumour and miosis that I could think of were a sympathectomy for paraganglioma causing miosis as a rare complication, or a bronchial Pancoast NET invading the sympathetics and causing a Horner’s syndrome, including miosis. These were both weaker connections than the obvious direct connection between “triad” and “miosis” of Horner’s syndrome, so some gymnastics were required to fit the meta-concept I’d chosen.

Why did you not connect the fourth card (>-< = CBC) to anything?

Well this one was interesting! When I saw that >-< symbol in the yellow card at the top without any words I initially thought it was the e-mail/e-message icon! Then I thought it must be something to do with the type of game this was and didn’t give it a second thought. Now I realise it stands for what you call a complete blood count (CBC) in America, which we call a full blood examination (FBE) in Australia, and I’ve certainly never seen it expressed like that before!

Makes me recall the time when I was working in a gestational diabetes mellitus clinic and it seemed to me that the midwifes were looking after an inordinate number of women with pulmonary emboli (PE) while the older obstetrician was ordering a lot of positron emission tomography (PET) scans. Turned out neither was true and both were talking about pre-eclampsia(PE)/pre-eclamptic toxaemia(PET)!

More importantly, when’s the Aussie version of Table Rounds coming out, Paulius?!

When you were making these teaching points, who did you imagine would benefit from reading them?

I definitely had my second-year medical students in mind. But medicine’s a two-way street and while they benefit (hopefully!) from my clinical experience, as I benefitted from my teachers and mentors, every week they in turn remind me of neuroanatomical and biochemical concepts I’ve long forgotten.

How long did it take you to come up with the connections?

Staying within my specialty and area of expertise meant these connections were all formed immediately through heuristic system 1 thinking as described above. So the connections formed in seconds and recording/explaining my reasoning took minutes. But had I been told not to use any concepts from my specialty area this would have taken much longer. I’m sure others would choose very different connections for the same concept pairs.

How can Table Rounds be used to gain further insight into learner development in clinical reasoning?

As I’ve progressed through medical training I’ve become increasingly aware of the role of cognitive bias in clinical decision-making. There’s also increasing evidence of the value of limitations in increasing creativity e.g. Twitter’s character limit. So as an ‘advanced’ game mode I propose adding contextual specifiers to the otherwise fairly broad table round concept pairs. These might be:

  • Location – A location specifier of Emergency Department (I think you call it the ER in America) for the concept pair tumour/dermatitis might make you think of terrible sunburn and the risk that this poses for melanoma in future. But a location specifier of General Practice (I think it’s called Primary Care or Family Medicine in the US) for the same concept pair might put you in mind of a developing cutaneous T cell lymphoma.
  • Timecourse – A timecourse specifier of “Acute” for the concept pair triad/FBE(CBC) might make you think of pancytopaenia post conditioning chemotherapy prior to a bone marrow transplant (or failed engraftment post). Whereas a timecourse specifier of “Chronic” might trigger Felty’s syndrome, which includes neutropaenia and potential thrombocytopaenia from splenomegaly.

Interview by Paulius Mui, MD

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