Time for a Time-out: The Value of a Diagnostic Time-out in Prolonged Fever and Lymphadenopathy

Occam’s razor and Hickam’s dictum: a dermatologic perspective

Diagnostic heuristics help ease the cognitive load in our day-to-day work. Occam’s razor or the rule of diagnostic parsimony is a diagnostic heuristic often applied in dermatology. Occam’s razor dictates that all things being equal, one diagnosis (as opposed to several diagnoses) should be sought to explain a patient’s presentation. While this can often be helpful, it can also obscure the full picture. Hickam’s Dictum is an aphorism expressing the opposite opinion: “patients can have as many diseases as they damn (or darn) well please.” This acknowledges that multiple simultaneous processes can be at play. This article delves into the implications of use of these approaches and offers tips through cases illustrating the limitations of Occam’s razor and when Hickam’s Dictum should be invoked.

A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain

BACKGROUND

Pediatric abdominal pain is challenging to diagnose and often results in unscheduled return visits to the emergency department. External pressures and diagnostic momentum can impair physicians from thoughtful reflection on the differential diagnosis (DDx). We implemented a diagnostic time-out intervention and created a scoring tool to improve the quality and documentation rates of DDx. The specific aim of this quality improvement (QI) project was to increase the frequency of resident and attending physician documentation of DDx in pediatric patients admitted with abdominal pain by 25% over 6 months.

METHODS

We reviewed a total of 165 patients admitted to the general pediatrics service at one institution. Sixty-four history and physical (H&P) notes were reviewed during the baseline period, July-December 2017; 101 charts were reviewed post-intervention, January-June 2018. Medical teams were tasked to perform a diagnostic time-out on all patients during the study period. Metrics tracked monthly included percentage of H&Ps with a 'complete' DDx and quality scores (Qs) using our Differential Diagnosis Scoring Rubric.

RESULTS

At baseline, 43 (67%) resident notes and 49 (77%) attending notes documented a 'complete' DDx. Post-intervention, 59 (58%) resident notes and 69 (68%) attending notes met this criteria. Mean Qs, pre- to post-intervention, for resident-documented differential diagnoses increased slightly (2.41-2.47, p = 0.73), but attending-documented DDx did not improve (2.85-2.82, p = 0.88).

CONCLUSIONS

We demonstrated a marginal improvement in the quality of resident-documented DDx. Expansion of diagnoses considered within a DDx may contribute to higher diagnostic accuracy.