Time Stamps

CME-MOC

Show Notes

  1. Reasoning is not just a cognitive process, but also a contextually situated activity. We do not reason in a vacuum. 
  2. Examples of many contextual factors that can add to one’s cognitive load AND alter their reasoning approach:
    1. Unfamiliar environment
    2. Ambiguous clinical questions
    3. Relative domain expertise
    4. Emotional interference
    5. Personal comfort level of the case
  3. Situation awareness is something that precedes, prepares, and  “primes” our mode of thinking and is largely affected by a person’s goals and expectations. Having clearly defined clinical goals is crucial to effective reasoning. 
  4. When someone needs to operate with insufficient domain knowledge, there is the natural tendency to slow down AND to deploy different reasoning strategies such as backward reasoning. The process can be deliberate or completely unintentional. 
    • A clinician employing “hypothesis-driven reasoning” (“working backwards”) starts with a clinical problem, generates a series of hypotheses about the patient’s illness, then tests each of these against the available clinical data. It is a time and effort consuming process. 
    • How rigorously one deploys such a strategy is often not dependent on the person’s actual expertise but rather their perceived familiarity of the problem. “Cognitive ease” refers to the phenomenon when we face a common diagnosis or symptom, the impression of familiarity can create a false sense of ease, which makes us more susceptible to diagnostic errors.
  5. Adaptive expertise entails someone’s ability to use existing clinical knowledge structures to come up with a novel solution when they face a complex, unfamiliar problem. 
  6. An adaptive expert tends to have:
    1. A solid knowledge structure of their own domain
    2. Is not satisfied by complacency
    3. Is cognitively ready to brace novel knowledge in an unknown territory

Transcript

C: Hi there, Core IM listeners. Today we have a case that is not necessarily diagnostically challenging like in the past episodes, but it’s a case that got me thinking about other aspects of clinical reasoning. And I am hoping to share what I learned with you. In past episodes, we have touched on some clinical reasoning topics that you probably have heard of many times by now. Fast vs. slow thinking. Problem representation. Illness script. Diagnostic schema. But I have been thinking, we usually talk about those concepts as if our brains were isolated entities that are just cold, independent processors of clinical information. But that’s not the case. A lot of times, my ability to think is very much affected by many contextual and environmental factors.

J: You’re right, Cindy. We simply don’t reason in a vacuum. And in this episode, we hope to convince you that the ability to recognize, adjust, and counter those external factors is a distinct form of expertise. One that we see in a lot of excellent physicians, though we might not always appreciate it. And one that’s worth honing in its own right. 

C: With Core IM, I’m Cindy Fang, here with my co-host, John Hwang, and this is Hoofbeats. Stay with us for the case.

So I was working the medicine consult shift one day, when I received a phone call.

Hi. I’m calling from the labor and delivery floor, and I have a new consult for you.

This is a 36 year-old G1P0 (gravida 1 para 0) with a PMhx of known vasa previa and elevated maternal serum alpha-fetoprotein. Earlier this week, at her 28 week routine ultrasound, it showed unfortunately intrauterine fetal demise. She was admitted to us for induction of labor, and was found to be hypertensive to the 180s/100s, and possibly in HELLP? We induced with oxytocin and delivered in the OR yesterday. Intra-op, she needed multiple rounds of IV labetalol, but her BPs are doing better now. 

The reason for the consult is that she’s hyponatremic. Her sodium this morning is 119, down from 134 on admission just 20 hours ago. We repeated the Na, and now it’s 117. Yeah.

Just to round out, she doesn’t have any other medical or surgical history. No home meds except prenatal vitamins. Right now, she’s on a magnesium drip for preeclampsia, and she’s also gotten nifedipine, oxycodone and NSAIDs, along with the oxytocin I mentioned intra-op. 

In terms of her vitals, she’s afebrile, her BPs are in the 120s-140s systolic, her heart rates are in the 60s-80s, and she’s satting 96% on room air. She has pitting edema to her shins bilaterally. 

Her other labs look for the most part stable or better today. Her white count is 13. Her platelets are stable at 84. Her AST over ALT are stable at 71/77. Everything else looks normal.

Can you take a look at her and help us with her hyponatremia?

Dr. Mednick: I think every time the consult phone rings, there’s always an increase in heart rate by about 10 to 20 beats per minute. Orthostatics kick in, I guess. And then when it’s a call from labor and delivery… it goes up even more. For this case specifically, this one was even harder for me, because it’s hyponatremia.

C: That’s Dr. Aron Mednick, who was the director of comanagement, a senior hospitalist and a consult medicine expert at NYU.

J: Yeah, he is a very experienced clinician in consultative medicine. Actually, I was once Aron’s med student. And I can tell you, it is very hard for me to imagine him actually becoming tachycardic when the phone rings. He’s just being modest.

C: Similarly, I bet he’s also being humble about hyponatremia being something that’s difficult for him. Though I do hear this comment frequently from both learners and experienced physicians alike, even though I know for sure everyone has encountered this problem plenty of times. 

Dr. Hwang, you recently participated in the Core IM Hyponatremia episode, no? What’s YOUR comfort level with it?

J: I… Hmm. Comfort level. Uhh, I would characterize it… as an enemy. It’s still an enemy. But it’s one I feel I’ve grown familiar with, even fond of. Whenever I see a sodium of 130, I think to myself, “Oh, it’s you again. A frenemy.” So yeah, I’m curious – let us see how Dr. Mednick approaches this case.

Dr. Mednick: I’m very concerned about this patient. I’m definitely going to go see this patient, of course, I’m not going to delay going to see her. I’m pretty concerned that there’s something complex going on and she’s going to need frequent monitoring of labs. She might need very careful monitoring of I’s and O’s and various intravenous fluids, maybe even hypertonic saline. And we’re not going to want to move slowly on this.

So I think that’s important to figure out early on, is disposition. How sick do we think this woman is? And what is the risk of something getting worse? For cerebral edema? For developing seizures or actual eclampsia?

I’m anticipating I’m not going to be seeing this patient alone. Right off the bat, I’m already concerned that this patient is gonna need to change levels of care. I’m probably going to recommend discussion with critical care at the same time that I see this patient, and I can work with them. 

Management is very crucial because if we spend too much time in a diagnostic realm at this point,we could miss the boat.

C: Dr. Mednick’s initial response is different from our past discussants, right? All our expert discussants in the past sort of dissect information in the traditional academic conference style. The patient is not right in front of them, they are not under any kind of pressure, the discussion is more academic than anything. Dr. Mednick here though,  he’s not performing slow analytic reasoning while smoking a pipe on an armchair. He’s entered a state of heightened vigilance and choosing to make management plans first, based on his assessment of the situation. I’ve got to say it’s a lot more realistic and similar to my reaction when I got the call.

J: We would say that our discussant is exhibiting appropriate situational awareness. And that’s a piece of jargon we’ve probably all heard a lot of in discussions about handoffs and patient safety. 

C: Obviously, I’m simplifying it to the point of butchering it, but the situation awareness theory as proposed by Endsley in 1995 basically says, we appreciate environmental factors, form a perception of “what’s going on”, and determine the appropriate problem solving strategy. Situation awareness is something that precedes, prepares, and  “primes” our Mode of thinking. When we sense a situation that calls for it, we enter a hypervigilant state.

J: This theory feels naturally relevant to fields in which critical thinking is often hamstrung by limited information, time pressure and high stakes. So anesthesia, emergency medicine, critical care, surgery. Some training programs have even tried to improve the situational awareness of their trainees, teaching them to recognize critical cues in their environment, or modifying their surroundings to minimize demand on working memory.

C: To quote Endsley, “SA is largely affected by a person’s goals and expectations which will influence how attention is directed, how information is perceived, and how it is interpreted.” And I thought that applies here. 

In real life after some panicked discussion with the primary team, I was told that they already consulted the ICU team – the intensivist was just wrapped up in an emergent case, but they would be coming to evaluate the patient for escalation of care. The consult question for me was that they wanted someone to help guide the diagnostic steps while waiting for the ICU team to come. If I volunteered that information, Dr. Mednick’s first reactions would probably have been more relaxed, more focused on the diagnostic approach, right? Here Dr. Mednick was forced to start by thinking about how well the OB floor can do intake and output, how often they can draw labs, is the level of care appropriate, etc. Just a lot of information to process in a short period of time, because he was led to believe the goal of the consult was the overall management of this hyponatremic patient. And as you can tell, the content of his reasoning was drastically altered because of that.

J: That’s an interesting point, Cindy. In consultative medicine, it’s actually not always clear what you’re supposed to be doing. When we’re managing our own patients as members of the primary team, our responsibilities are broad, but comparatively well-defined and concrete. Interview patient. Reconcile med list. Adjust vanc dose. And when you’re a discussant at a case conference or on a podcast episode, it’s obvious what is expected of you. Talk smart, sit up straight, dispense wisdom, truth and the diagnosis. But every time the consult pager goes off, someone in Dr. Mednick’s role has to figure out: What am I being asked to do? What should I do? Do I approach this case as a problem of diagnosis or a problem of management? What is the appropriate level of involvement here? Am I expected to advise, or to give my assent, or to advocate for a particular intervention? Figuring all this out takes up cognitive bandwidth.

C: So if we accept that having clearly defined goals and expectations affect both the mode and the content of our thinking, how do we apply that knowledge in our daily clinical life to make improvements?

J: Well for starters, I think this means that when we call a consultant, we ought to do this thinking for them as much as possible. Make our questions, expectations and goals very explicit.

C: I have learnt to clarify questions when I take consults too.

J: And honestly, this is not just limited to asking and taking consults. When I have a very complicated patient with many problems, I should habitually set concrete clinical goals before I get lost in their many, many problems.

C: Alright, after all that, let’s see how Dr. Mednick thinks through the case.

Dr. Mednick: The next thing, you know, is really “What is driving it?” When I see a rapid drop in sodium like this, one of my first questions is just to rule out pseudohyponatremia. And so for that, I would need to know what the glucose is. When I see a rapid decline in anything or rapid incline in anything, I always think about things that we did to the patient. Things that are iatrogenic. One of the big causes is drugs. And so one thing that I think is very important as my first peri-operative point is to always take a look at the OR flow sheet, all electronic medical records and paper records. Sometimes it’s very hard to know what actually happened in the OR. If you just look at the med administrations that happened in the hospital, you might miss some things that happened in the OR.

See what medications were actually given, see how much fluid was actually given, see how much blood loss actually occurred. See how many pressors were given, and not just trust the brief post-op note.

So this reason why this is important in this particular patient is this particular patient was getting oxytocin. And I presume she also got fluids, during the OR. A rare occurrence, but something that is concerning, that can definitely occur, is oxytocin combined with excessive IV fluids can cause a water intoxication syndrome. 

She sounds like she’s hypervolemic in terms of the fact that she has edema, but there are still multiple causes of her hyponatremia. Preeclampsia very rarely can have hyponatremia. 

And if it’s an SIADH picture, which is essentially the same reason… the SIADH is very similar to the reason why you get this hyponatremia with oxytocin and presumably with preeclampsia as well. You’d be managing it very similarly as well. You’d be avoiding hypotonic solutions, try to avoid her taking things by mouth, um, uh free water by mouth.

There are a lot of things that are done on those services that I’m not familiar with. And going into the case, being very well aware that you are endeavoring on things that you might not be comfortable with is very important. I think in consultative medicine, I am looking up stuff so much more than I am in my usual day to day. And that’s just part of it. And also pairing with people who will know this well is very important. I mean, the oxytocin question is not something I would presume to be correct about. It’s something that I will question and I will talk to the obstetricians, the MFMs and I’ll say like, listen, this is an entity that exists. Do you think that I’m barking up the wrong tree by considering oxytocin and fluid to be the etiology of this? They might say they do this all the time and never see this. And that would be helpful, I have to acknowledge their expertise.

C: When Dr. Mednick mentioned going through the OR flow sheet, my mind went: “Ahhh, that’s the painful part about taking a consult. Looking up events and medications through a separate record keeping system. Going through medications or events that I don’t quite understand.” It’s treading through an unfamiliar mental environment that definitely slows me down everytime. It’s something that adds to my cognitive load, even when those records may or may not be completely unrelated to the case. I wonder if it brings extra cognitive load for experts like Dr. Mednick when he staffs a consult case? I bet it doesn’t anymore.

J: I would guess it’s an automatic habit for him by now.

C: John I don’t know about you, but severe hyponatremia due to preeclampsia or oxytocin, or any OB related medications? Totally foreign territory for me, and I assume it’s the case for most internists.

J: It’s interesting, because the way in which he thinks about this patient’s hyponatremia is immediately recognizable – it’s how any of us would think about hyponatremia in a medicine patient. Real or not real? Iatrogenic or not? Volume up, volume down or normal?

C: Dr. Mednick had to apply this familiar framework in a very unfamiliar domain where none of us has sufficient domain knowledge. And I have to be honest with you about something too -when I staffed the consult,  I completely overlooked the possibility of oxytocin being a culprit. So I was curious, why is it that I missed something like that and he didn’t?

J: I can’t tell you the answer to that for certain, Cindy. But if you noticed, our discussant is describing his thought process as one of backward reasoning, and I think that’s potentially significant to your question.

C: Backward reasoning? That’s a phrase I haven’t heard since episode 1. Can you refresh my memory?

J: Sure. Remember we had said forward reasoning is data-driven reasoning. A clinician will start with data – findings, signs, symptoms – and by putting these things together they work their way toward a diagnosis. 

Backward reasoning is hypothesis-driven. You start by making a conjecture, then you go back to examine the data to see if things fit. So for example: “Theory: Is this something we did to her? Is this medication related? Our action: We’ll go back, we’ll examine the OR flow sheet and medication history closely. Oh, it is oxytocin-related? Does that fit the picture? Let’s look further into it. That’s what I’m talking about.

C: Got it. Now, in real life it does not make so much sense to be so cognizant of if we are going forward or backwards, right? We probably go both directions interchangeably when we solve a case.

J: No, absolutely. This is descriptive vocabulary, not prescriptive.

C: Here though, it’s worth pointing out that Dr. Mednick took a backward reasoning approach. It is a signal that he is deliberately examining his data with extra caution because he is in an unfamiliar domain. 

Remember, we say that backward reasoning is a strategy that takes time AND effort. Imagine going through a case and actively making a hypothesis, going back to find data that supports or overturns it, and then doing it all over again until you get to the correct diagnosis. It’s not how we typically reason when we go through a relatively “easy case.”

J: I don’t disagree with any of that, Cindy – but for the sake of argument, I’ll challenge you here, and I’ll ask you: How is it that special? When any of us staffs a consult case, it is very common to pause and ask, can this be iatrogenic? It seems very natural to switch to a backward reasoning approach. So if there’s a deeper significance to this observation, Cindy, I think you should explain it.

C: I’m so glad you mentioned it, because that’s a perfect segue for me to bring up what I really want to talk about in this case: adaptive expertise. 

We are all very familiar with the idea of routine expertise. It’s what’s been modeled in morning reports and in our past episodes: someone who effectively uses their sophisticated knowledge-memory structures to solve routine problems. Adaptive expertise is something else.

J: So for any of you who may have heard of the term “adaptive expertise”, just be aware it is a phrase with slightly different definitions in different fields. Researchers in health care would define adaptive expertise as the ability to use existing clinical knowledge structures to come up with novel solutions when they face a complex, unfamiliar problem.

C: Think of a surgeon who had done hundreds and hundreds of appendectomies. All of a sudden he’s asked to do an emergent appendectomy in the middle of the battlefield with limited supplies and resources. What he possesses to carry out that procedure successfully is what we call adaptive expertise.

J: Adaptive expertise is the quality that doctors in popular culture – depictions of doctors in popular culture – seem to possess in infinite abundance. Think of ship’s doctors on Star Trek curing planet-wide plagues. Or House performing surgery even though he’s boarded in what – rheumatology?

C: For the purposes of this episode though, I would like to use the broader definition of adaptive expertise when it was first introduced by Hateno & Inagaki, one that focuses less on coming up with innovative solutions, but more on how an expert adapts in an unfamiliar environment. It’s the ability to perform at a relatively high level in an unfamiliar situation because the person is able to transfer their knowledge or skill set appropriately to solve a problem. In this case, the patient’s sodium was dropping at a precipitous rate, which triggered the iatrogenic hypothesis and led to the close examination of the medication list. But does every case warrant the same kind of stance? Everytime we staff a surgical consult, it’s so easy to open up that OR flow sheet and see a sea of unfamiliar medications, and be tempted to ask, “Hmm, is the problem at hand caused by something iatrogenic that I do not know about?” And before I know it, I’m looking up every one of the medications one by one. That’s not really an efficient use of my time, when I’m staffing every surgical consult, right?

J: There’s a well-known study in which they challenged expert historians to come up with a thesis by analyzing primary literature from the Civil War era. The first historian was a specialist in Civil War History, and their analysis was – as you might expect – rich, sophisticated and efficient. A second historian – an equally accomplished academic, but not a specialist in the Civil War era – floundered at first. But the authors observed that he was able to put together a coherent analysis by adapting specific strategies: They note the way that he asks questions, his habit of revisiting his earlier assessments, his methodical reconciliation of apparent contradictions between source texts. Notably these strategies were not used prominently by the first historian, who could rely on his pre-existing knowledge to make large inferences and leaps. So one might say the second historian’s use of these strategies were a marker he was outside his domain of comfort – yet they enabled him to succeed nonetheless.

In medicine, when we’re dealing with unfamiliar problems, we often don’t know enough to make sound inferences – to engage in grand, data-driven leaps in forward thinking. So instead, we flail. We speculate, we hypothesize, then we go backward into the data, to see what sticks. It’s not as sublime. But ultimately what matters is how well we implement and balance these strategies.

C: In this case, the patient’s sodium was dropping at a precipitous rate, which triggered the iatrogenic hypothesis and led to the close examination of the medication list. But does every case warrant the same kind of stance? Everytime we staff a surgical consult, it’s so easy to open up that OR flow sheet and see a sea of unfamiliar medications, and be tempted to ask, “Hmm, is the problem at hand caused by something iatrogenic that I do not know about?” And before I know it, I’m looking up every one of the medications one by one. That’s not really an efficient use of my time, when I’m staffing every surgical consult, right?

J: No, of course not. That instinct, being able to recognize when that approach will be profitable versus when it will be wasteful – that is the mark of the adaptive expert.

C: Funny you mentioned that. We will definitely come back to that example later in the episode.: 

J: But now that I’m hearing you say this out loud, Cindy, I have to ask: Are we just saying experts implement and execute the same strategies as us, just better? Because that is an unsatisfying answer; that is not what our segment is supposed to be about, right? How do we get better? That’s the question.

C: I agree with you, but I also have to be honest: I don’t have an answer. I hope I have convinced you that when we reason in an unfamiliar environment, yes we slow down, but we also consciously or unconsciously utilize different reasoning strategies that may compromise efficiency and may or may not be appropriate for the situation. I do think that being cognizant of the fact is at least the first step. 

J: So far we’ve discussed many environmental factors that add to our cognitive load: unfamiliar physical environments, ambiguity of questions in consult settings, increased difficulty in acquiring raw data (like OR flow sheets), and the stress we experience when we’re in an unfamiliar domain. Dr. Mednick identified one more for us.

Dr. Mednick: That’s part of the stress about getting called to labor and delivery. That no matter what the situation, the internist being called to labor and delivery is a connection between something that’s negative that’s going on with something that was supposed to be positive. And that conflict is always dramatic. It’s always much more dramatic than the geriatric patient who comes in with pneumonia – because that’s not surprising. It can still be significant for the patient, but it doesn’t have that conflict of, “This is supposed to be a happy moment in my life. Why am I seeing an internist? Why am I seeing a critical care doctor?” And so that conflict induces a tremendous amount of emotion, and often in a patient who’s not used to hospitalization and not used to illness. So it’s a very, very difficult situation.

C: When I asked the primary team if the patient was having any neurologic symptoms due to the drastic drop in Na, they told me that the patient had a headache from crying all night. I distinctly remember standing at the door and doing deep breathing before I entered the patient’s room. I just did not know how to approach her because I was never trained to care for a patient who just went through what she went through before. Do I offer condolences? Do I avoid the elephant in the room and go straight to my interview?

J: It’s interesting you say that, Cindy, because we’re not strangers to emotionally-fraught situations in medicine, right? We’ve all had hour-long family meetings. We’ve been at palliative extubations. We all did that OSCE on breaking bad news. Heck, we’ve experienced COVID. But I’m guessing what you mean, Cindy, is that this was as much an unfamiliar emotional context as it was an unfamiliar clinical one.

C: Some of my emotional discomfort definitely came from my unfamiliarity with this specific situation. I know how to walk into a room and tell a patient about their newly-diagnosed metastatic cancer and multi-organ failure – because I was trained to do that. But I did not know how to walk into a room where a young woman had just lost her child. 

Our discussant here is wise enough to anticipate this problem. Identifying these emotional stressors is the first step in managing them; that way, we have more time and cognitive bandwidth to think about the actual clinical problem. Dr. Mednick’s suggestion is to ally with the primary team: Check in with them before visiting the patient, maybe even go to the bedside together (if their relationship is good). Just so we’re not random people barging into the room.

J: Why don’t we move on to the labs that our discussant was interested in seeing?

So just to recap, on the morning of hospital day 2, when medicine is consulted, the serum sodium is 117. Her glucose is normal. 

The urine osmolality at that time is 442, and her urine sodium is undetectable, with a FeNa of 0.1%. Her urine protein/creatinine is 12,000 mg/g.

On exam, she is alert with normal vital signs, fully oriented, and answers questions appropriately. Her family and nursing staff haven’t noticed any confusion or abnormal behavior. 

The next repeat sodium, in the afternoon, is stable at 117. By this point, the patient’s urine output starts to increase; she puts out a total of 1.1 liters during that 8-hour nursing shift.

C: Listeners… What would you write in the initial consult note?

Dr. Mednick: I have a hard time responding to her hyponatremic state. She has no sodium at all in her urine, right. So it’s possible her insult already occurred and that now she’ll start to improve, um, you know, on her own. And maybe she doesn’t require any intervention yet. She’s probably going to require a diuretic, uh, to get rid of some of this edema, but if her sodium starts to improve like this and she’s not showing sodium, um, and she’s very started to improving with, with minimal intervention, except for withdrawing hypotonic fluids….she definitely has, you know, a lot of protein in your urine, so it’s consistent with her preeclampsia. So she’s not fully out of this, this, this window…  I think fluid management is going to be so mething I have to keep a close eye on.

C: It’s a confusing picture, to be sure. The urine in the morning was concentrated – the urine osmolality was high. But with that sudden increase in urine output and the stability in the sodium level,  Dr. Mednick is suggesting that whatever caused the patient to be hyponatremic may have been in the process of reversing. He’s saying the correct action might be to watch to see whether her kidneys put out enough free water. 

Her urine output continued to increase. On the second hospital day she put out 5.5L, and an additional 4L on day 3. As this was happening, her serum sodium level steadily increased, rising to 125 by the end of day 2, and to 133 by day 3, and normalized on day 4.

J: So what happened here, Cindy?

C: In the end she did not require much intervention. It was difficult to tell if her hyponatremia was driven by hypervolemia secondary to preeclampsia, or was there a combination of hypervolemia plus SIADH. But it became very clear in the next few hours that she entered a state of brisk auto-diuresis, which according to the OB team and the senior nurses on the floor is not uncommonly seen in patients recovering from pre-eclampsia. Like what Dr. Mednick predicted, it all came down to fluid shifts at the end.

J: Have you seen any other cases like this since?

C: I’ve seen one more. Not as prominent as this.

J: Interesting. So you’ve seen one more…

C: A lot milder though.

J: But same phenomenon. Is there any explanation for why this happens?

C: I’m not quite sure. Before that case I have never seen patients with preeclampsia. Haven’t seen that many OB patients in general, to be honest. Seeing a human body retain and auto-diurese more than 10L of fluid in the span of three days fascinated and scared me at the same time. So I read up a bit on severe hyponatremia in pre-eclampsia patients. I learned that it’s very rare, but there are case series out there. In some complicated cases the management even involves consideration of fetal sodium, risk of fetal seizure, fetal urine output, and most importantly, determination of timing of urgent delivery.

J: So most patients end up like your patient? They do okay?

C: In most cases, once the patients get out of the pre-eclampsia state after delivery, the sodium seems to always rapidly normalize like in our patient

J: Interesting.

C: In most cases, preeclampsia patients with severe hyponatremia are thought to have hypervolemia, SIADH, or a combination of the two. In patients with hypervolemia, it is thought that the inadequate placental blood flow leads to placental angiogenic factors and endothelial growth factors, which lead to maternal vascular dysregulation, and ultimately proteinuria and edema. The volume retention, and in most patients also nephrotic range proteinuria, lead to low effective circulating volume and the turning on of ADH release much like in cirrhosis and heart failure patients.

J: But then you mentioned sometimes the ADH is probably more inappropriate?

C: SIADH in pre-eclampsia is more complicated. Of course there are pregnancy-associated factors like stress, pain, or the oxytocin Dr. Mednick spotted. But those factors are fairly common, right? And we don’t see that many severely hyponatremic cases in hyponatremia patients. There are some postulated mechanisms that I don’t quite understand, such as “The defective placenta in patients with pre-eclampsia does not produce sufficient vasopressinase.” That’s a placental enzyme that inactivates ADH.” It’s a mouthful – I’m reading what I don’t understand at all

J: Cindy, you asked me at the beginning of the episode what my personal comfort level is with hyponatremia, right? And you also mentioned that most of us, regardless of our level of training, have seen a lot of hyponatremia cases, at least in medicine.

So, just one more time, I’m going to paraphrase something that Dr. Gurpreet Dhaliwal has said: “There is a difference between an experienced clinician and an expert clinician.” If we had to ever choose a motto for Hoofbeats, Cindy, I think that might be it. For any given clinical problem, most of us learn, and then we improve, until we get to a point where we are good enough. And then I think what happens next is key. In many cases, we stop learning. Seeing a hundred elderly ladies with tea and toast diets on thiazides would make me feel very comfortable about seeing hyponatremia, but obviously, that experience would not make me an expert. If I was striving to be an expert in hyponatremia, I would be seeking out the kind of complex cases that you just gave us – from you, my colleague; from journal articles, from conferences, from podcast episodes, and so on. It’s a sad but simple truth, I think: Comfort breeds complacency. And conversely,  putting ourselves in unfamiliar situations – that’s the key. It’s postulated that variation in daily practice is a necessary condition to build up adaptive expertise.

C: Listening to Dr. Mednick’s response to this case made me wonder: How can I think better next time I get a hyponatremia consult from OB? What do I need to do to be a better med consult, like Dr. Mednick?  How do I feel less helpless next time I staff a consult in the unfamiliar surgical or OB world where there’s a lot of domain-specific knowledge?

J: We can only scratch the surface of your question in a 30-minute episode, but for starters I think it’d be helpful to identify: What are the hallmarks of an adaptive expert?

C: Well first of all, they have a deeper understanding of their own domain.

J: And I think that deeper knowledge often reflects a tendency to be dissatisfied with answers that are merely “sufficient.” For these clinicians, simply completing a task isn’t enough; the coequal goal is always to deepen and strengthen their knowledge, even at the cost of being a little uncomfortable, or of having to discard old knowledge structures that prove inadequate.

C: Allow me to take a tangent, because what you said reminded me how I encountered some brilliant providers at the height of COVID. When things were really bad, our institution activated an army of volunteers to help care for COVID patients who were hospitalized. Some of these people are endocrinologists, ophthalmologists, residents from the orthopedics department. Needless to say, I truly appreciated their help, and we wouldn’t have survived without the extra hands on the floor. While most of them found hospital medicine very foreign to them, I did notice that some of them thrived in the crazy, even-foreign-to-me COVID-era hospital medicine better than others. All of those individuals possessed what you mentioned – that readiness, that eagerness to adapt and learn medical knowledge even though they were not expected to come back to medicine again. And those qualities in my mind are what sets me apart from some experts like Dr. Mednick.

Dr. Mednick: I was consulted at our orthopedic hospital for somebody who was post-shoulder surgery. And pretty recently post-shoulder surgery. It was, you know, within, I say within 12 hours of shoulder surgery. And the patient was feeling short of breath and was having significant shortness of breath and, I was a little bit new to consultative medicine at the time. And so I did have to look up causes of shortness of breath, post shoulder surgery, just to make sure that I had a good sense of, Is there anything specific to shoulder surgery? Actually, I thought there’d be nothing specific to it, but there is. Very often patients get a regional block for shoulder surgery, and that regional block can actually cause paralysis of a hemidiaphragm. And so I got a chest x-ray and sure enough, the chest x-ray had a raised hemidiaphragm on the side of his shoulder surgery.

C: Earlier this episode we said it’s so easy to go backwards and ask “Is this iatrogenic – is the consult problem related to the procedure or to anesthesia?” when we take a consult, right? Well, I was surprised after hearing Dr. Mednick that I never once looked up “diaphragm paralysis and shoulder surgery”, even though I staffed many consults at the affiliated orthopedic hospital. I think it’s my cognitive ease talking, right? A dyspnea consult from the ortho team seems so bread-and-butter.  It doesn’t lend me that “I’m treading through an unfamiliar environment” nervous feeling, and I usually I just fall back to the same schema that got me through 90% of medicine cases. I mean, when I staff a case like that, I still do enough backward reasoning to ask questions like “Is this CHF from too much intra-procedural IVF?” or “Is this pulmonary embolism? ” or “Is this post-operative pneumonia?” But I was confined to the comfort zone of common medical etiologies. Dr. Mednick was more intellectually curious than I was, and obviously better at asking the right question

J: Another reason why we might not be digging deeper is assuming the primary team would take care of the domain-specific problems: Telling oneself “I am here to deal with my problems (in my case, “medicine problems”). “Surely the anesthesiologist will notice a diaphragm paralysis they caused – who am I to comment on that?”

C: Whenever I talk to Dr. Mednick and my colleagues who are co-management experts, I’m always very impressed by their surgical domain knowledge that I’m sure they learnt from not just staffing consult, but they definitely did additional reading, research, and talking to the surgical teams. They did not confine themselves and have been actively seeking knowledge outside of the expected domain. And I used to do that when I first learned to staff consults as a resident. Well, back then I did it in an aimless fashion because I was not good at this backward reasoning thing, so I was literally reading about every procedure complication and looking up every anesthesia medication. It was a stupid way to do that, but I was a lot more intellectually curious. I wonder what happened to me. Why am I not doing that anymore?

J: But the factors we mentioned in this episode are always in our way: time constraint, case load, the cognitive strain from various sources.

C: I know it’s not typical good hoofbeats advice, but I hope by talking about it helps to be more cognizant of those restraints. But It’s also helpful to make concrete goals, like I will try to take one case and do case related learning while on I’m on consult

J: But remember it’s also about being smart with your resources, knowing which case warrants that comb-through… which lessons are worth your valuable brain space.

C: Alright. Today we talked about how we do NOT reason in a vacuum. There are a lot of contextual factors that interfere with how we think

J: And by seeing our discussant approach a consult case from obstetrics, we had the opportunity to talk about the concept of adaptive expertise, and how it is a distinct skillset, to be able to apply your knowledge in an unconventional and unfamiliar environment

C: Although very rare, I got to take care of a patient with severe hyponatremia associated with pre-ecclampsia, which reminds me I am not an expert in hyponatremia, and once again, the idea of cognitive ease. Repeat exposure to a problem does not make me an expert.

J: Alright listeners, that should do it for this episode. As always, let us know what you think. Special thanks to Drs. Amy Ou, Shreya Trivedi, and Marty Fried. And thanks to our audio editor for this episode Daksh Bhatia, along with our other CoreIM colleagues.

C: I would like to say thank you again to Dr. Mednick for both helping us with the episode, and all his work on the co-management service that allowed me to learn so much about consult medicine after my residency training. 

J: Dr. Fang and I are general internists and faculty with the NYU School of Medicine. 

C: Opinions expressed in this podcast are our own, and do not represent the opinions of any affiliated institutions, nor should they be construed as medical advice.

J: Thank you for joining us. With CoreIM, I’m John Hwang.

C: And I’m Cindy Fang.. See you next time.  

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