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Differential Building

Broad differentials are the foundation of clinical reasoning skills

In many cases, learners apply management patterns to common cases (“this is a chest pain rule-out ACS” or “she has abdominal pain and is really tender. I want to get belly labs and a CT") without thinking carefully about what they’re looking for or why. In our often rushed clinical arenas, we sometimes let this slide---or worse, assume the learner has done the rigorous thinking on their own and is presenting their thoughtful distillation of the presentation. Ask learners to dig deeper by providing short, reasoned differentials for their patients. Then ask them how the work-up will affect prioritization of the differential.
Consider revisiting the differential at multiple phases of the ED visit:

  • With the chief complaint alone

  • After the intake or nursing notes are reviewed

  • Before and after the history and exam

  • After attempted symptom control

  • After labs and/or imaging studies

  • After periods of observation or procedures

At a minimum, encourage learners to identify diagnoses in 3 important categories:

  • Likely diagnoses

  • Can’t miss conditions that should be ruled out

  • Less likely / unlikely diagnoses


Short mnemonics like SPIT, which asks learners to identify non-overlapping diagnoses that  are serious, probable, interesting, and treatable, are great to us eon the fly in the ED.


PINNACLE TIP: You can use commitment to a differential as part of the One Minute Preceptor and then probe for supporting evidence to assess and provide feedback on clinical reasoning.
GO FURTHER: This process is essentially what the MDM part of your note is all about. If your leaner has the diagnostic reasoning part under control, talk about how you document the manner in which these considerations were addressed. It’s even better if you give them feedback on their MDMs. 

Additional resources:

Eva KW. What every teacher needs to know about clinical reasoning. Medical Education 2005;39(1):98–106. 





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