IM Reasoning

Conversations to inspire critical thinking in clinical medicine and education

Welcome to IM Reasoning with your hosts Dr. Art Nahill and Dr. Nic Szecket, two general internists with a passion for teaching clinical reasoning.

Join us for case discussions, conversations and interviews that explore issues important to medical students, trainees and practitioners of clinical medicine, with a special focus on clinical reasoning, the once-mysterious process behind the remarkable abilities of the master clinician.

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68 comments

  1. Stephanie Davis says:

    Hi Nic and Art,
    I’ve recently been listening to your fantastic podcast and really enjoying this. I’m a public health physician who works part time as a supervisor on the Australian Field Epidemiology Program, and part time as a GP registrar and so I have been finding your podcast interesting from both the angle of improving my clinical reasoning, as well as the teaching and training angle. As part of my work on the Australian Field Epi Training program I’ve recently been looking at how we train people in outbreak response, and particularly at aspects of supervision – it’s an interesting area as there are some clear areas of similarity with clinical medicine but also some distinct differences (for example the standard of what constitutes a good outbreak investigator/public health practitioner is generally a lot less well defined than say an internal medicine physician). I ran a workshop on effective supervision last year in Cambodia at a conference for field epi. training programs in the Asia-Pacific region – am now wishing I’d listened to your feedback episodes before doing this!
    In any case, I just wanted to say thanks for your work. It’s a fantastic resource (and highly entertaining) and I’ll continue to avidly plug the podcast to colleagues.
    Cheers,
    Steph

    1. Nicolas Szecket says:

      Wow Steph, your work sounds pretty amazing. Glad you find some relevance in what we do- it’s really gratifying to hear!

      Art and Nic

  2. David Berger says:

    Nic and Art,

    I am a colleague of Casey’s in Broome and he sent me the link. This is a fantastic podcast, interestingly presented and with what is a novel take, but which resonates so deeply with our everyday experience as diagnosticians in this complex environment.

    Keep it up!

    All best,

    David Berger

    1. Nicolas Szecket says:

      Wow, Broome sounds like the place to be! Keep up the good work. Glad you find what we do of interest.

      Art and Nic

  3. Casey Parker says:

    Hi Nic and Art

    Just discovered your excellent podcast… somehow managed to evade me despite many shared ideas!
    Will be giving you guys a plug for our education sessions and to the wider audience out there in the ether!
    Great stuff
    Keep it up

    Dr Casey Parker

    1. Nicolas Szecket says:

      Hi Casey. Glad you discovered us. Had a look through your blog- lots of great stuff there as well. Keep up the good work!
      Art

  4. Aseel says:

    Dr Nahil
    I am listening to this great series
    I was your house surgeon 9 years ago in Auckland Hospital I am a rural Gp in Australia
    I find this very very useful
    And very interesting

    1. Nicolas Szecket says:

      Yes Aseel, I remember you! Glad you’re finding the podcast useful. It’s great fun to produce, it’s really educational for us as well, plus it beats doing ‘regular’ work! Be well.
      Art

  5. Thanks for plugging my diagnostic iOS app DxLogic on one of your recent podcasts! If you didn’t know, I did release it for Android a few months ago too. Finally, it can be accessed from any desktop device at http://www.lrdatabase.com

    Please let me know if you have any comments or suggestions about my project.

    1. Nicolas Szecket says:

      Michael, sorry for the delayed response. So glad you listen to the podcast! Really think your efforts are worthwhile and use your app with students and junior doctors regularly. Keep up the good work!
      Art

  6. Jimmy Chance says:

    Hi Dr. Szecket and Dr. Nahill,

    Thanks for the latest episode on the evidence behind various clinical signs, I found it particularly fascinating as I have often wondered about the evidence of a lot of the historic practices that we continue to use.

    Just the other day I put in a request form for a CTPA for a woman in whom I suspected a PE (Wells score = 7) and I wrote on the form “Left leg positive Homan’s sign.”

    I know you said on the podcast “we shall never mention Homan’s sign again,” as I now know that it lacks any clinical utility, however I do believe it can still be useful for young docs to include signs like Homan’s when requesting a scan from a radiologist, especially when it is after hours. As the addition of an associated physical sign (albeit a useless one) may be the added weight we need to get a scan that our seniors are demanding of us.

    The caveat being that the radiologist must not have listened to your latest podcast and see through our non-differentiating clinical signs…

    I look forward to more critical appraisal of physical signs!

    1. Nicolas Szecket says:

      Thanks Jimmy. Listen, we’ve all been there, late at night, trying to wrangle what we think is best for the patient, using whatever means we have available, INCLUDING useless physical signs (assuming that the person on the other end of the phone doesn’t appreciate the poor likelihood ratios for that sign)! I would argue though that with a Wells score of 7, the pretest probability of PE was already so high the scan just should have been approved- end of discussion!

      Regards, Art

  7. Nyein Oo says:

    Hi Nic and Art

    Stump the chumps is superb! It’s excellent and fun and also make us easy to memorize the case and the disease. I remember symptoms and signs of AOSD now 🙂 Please kindly do more of these. I love this episode so much plus the jokes 😀 Thanks a million for teaching an interesting case.

  8. Randy Goldberg says:

    Suggestion: when doing Stump the Chumps, please include US values for labs. Those of us listening in the US are completely lost with your SI values…

  9. Randy Goldberg says:

    I’m a hospitalist and clinical faculty at New York Medical College/Westchester Medical Center, in the suburbs of New York City. I was privileged, twice this year, to meet Dr. Jeff Wiese from Tulane in New Orleans. Jeff lectures often on clinical reasoning. I strongly recommend his book “Teaching in the Hospital,” which provides both a framework for thinking and teaching, and a series of Socratic dialogs specifically designed to make learners think about their processes.

    1. Nicolas Szecket says:

      Thanks for the recommendation Randy. Have heard of the book but will definitely have a read.

      Art

  10. Stephen Martin says:

    Hello Art and Nic,

    I’m a GP registrar working in Canberra, Australia and I’ve been using my half hour commute over the past couple of weeks to listen to many of your podcasts. Thank you for your time and energy and good humour, I’m really enjoying them.

    I have a comment / question about the content in one of the early podcasts – about framing biases and how they impact on the lives of junior doctors. It has been my experience as a junior (intern, resident) that, while working in ED or on the wards that, in order to “sell” the patient to a particular speciality for consults or to take over care it’s often necessary to consciously emphasise particular aspects of the case to even get the registrar to see the patient. We all knew the “nice” registrars that would help us with questions / uncertainties over the phone, and we also knew those that simply acted like “walls” unless you could convince them very rapidly that they needed to see a patient. I guess this isn’t really a cognitive bias on the part of the junior in that it happens quite consciously(!), but I worry about the impact on patient care, the effect of priming the registrar and on whether it unnecessarily compromises care because it “fixes” a diagnosis too prematurely. I see it as consequence of system problems, really, involving patient handover practices, workload and time constraints.

    Do you have any advice for juniors in how to approach day to day ward work that requires patient handover to seniors from other teams, and are there any system changes that might help solve these issues? For example, at one hospital here in Canberra the majority of ED patients go directly to a general medical ward prior to then going under a sub-speciality. I see the benefit of this as having a general physician care for them for a period of time prior to sub-specialties being involved.

    I just re-read that last part and I’m sorry it’s so long-winded! I blame the late hour.

    Thanks again for your great podcast and all the best.

    Steve

    1. Nicolas Szecket says:

      Thanks Steve. An excellent observation that we can all relate to. It is true, and in some ways unfortunate that we feel we have to “embellish” the case in order to gain the attention of the service we are consulting. It becomes a fine balance between, achieving your goal of having the service review your patient, and not “over-biasing” the recipient of the handover.
      The classic case is Radiology; how do you convince the radiologist that it is worth scanning your patient? Well, you might emphasise the abdominal pain, even though you felt that it was not really the main feature of the symptoms. You then may have to de-bias the radiology report if it doesn’t match the clinical picture…
      Consulting services like it when you have a good idea about the diagnosis, because this is less work for them. Who wants to hear, “please come and solve this complete mystery. I have no idea what’s going on.”? Instead, I would suggest that in your handover you postulate the diagnoses that you are considering that justify you phoning them, and then highlight the features of the case that you think don’t quite fit. This forces the consulting service to actively consider the inconsistencies. That’s one thought anyway. How do you deal with this?
      Nic

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