When assessing ill children, it is easy to presume that the problem is an uncomplicated viral infection. Most of the time it is. The odds are severely stacked against a more significant diagnosis to the extent that it is easy to become overly presumptive. This, combined with the fact that a simple and benign illness will share many features with a rare or dangerous illness means that spotting the unusual or harmful diagnosis is very challenging indeed.
Much of the work done on cognitive and diagnostic error takes the errors and then works backwards. For a long time, there have been reports on the number of deaths in healthcare that are related to error. (1)
These are reverse-engineered and start from the point of the problem. People died – what is the evidence that there were any flaws in the care/ diagnosis/ treatment?
This is very different from the alternative approach of People had a healthcare episode- what happened next? Outcome-based stats are dangerous in that respect. If you have 10% more adverse events than your colleagues but see 50% more patients (because you’re awesome at your job) then please come and work with me. You might flag up as a dangerous clinician if someone looks purely at incidents rather than the big picture.
I think that the most effective clinicians are those capable of recognising well children and capable of changing gear when something is unusual. This is sometimes referred to as type 1 and type 2 thinking as per the model described by Croskerry. (2)
Using this model, we are most efficient when we are thinking intuitively and making gut feel decisions (type 1 thinking) and most effective at making the more complex diagnoses and managing the most dangerous scenarios when we are more considered and thorough (type 2 thinking).
Let’s use this example to consider a child with non-specific symptoms such as fever, rash, lymphadenopathy and pharyngitis. The reasonable but also dangerous assumption is that the child has an uncomplicated viral illness. The possibility of another outcome is small but the consequences of missing an alternative diagnosis are great. So, we need to use type 1 thinking to be efficient and be prepared to go into type 2 thinking when needed.
The obvious questions are then, what am I looking for and when do I look for it? Guidelines on the subjects of febrile children, URTI in children and recognising complications such as sepsis tend to be written as if the problem was one dimensional or that the same guideline could be used in every circumstance. This is one of the reasons that guidelines can sometimes frustrate. Clinicians don’t think that way, so it jars when a “fits all sizes” guideline over-simplifies such a complex process.