session m11 reducing diagnostic error: a practical...
TRANSCRIPT
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Reducing Diagnostic Error: A Practical WorkshopBob Trowbridge
Harry Hoar
Doug Salvador
Session M11These presenters have
nothing to disclose
December 6, 20158:30AM – 4:00 PM
#IHI27FORUM
Faculty
Bob Trowbridge, MDCo-Director, Intro to Clinical Reasoning, TUSM
Director, Faculty Development and General Internal Medicine
Maine Medical Center
Harry Hoar III, MDDivision Chief, Pediatric Hospital Medicine
Director, Pediatric Simulation
Baystate Medical Center
Doug Salvador, MD MPHVice President, Medical Affairs
Baystate Medical Center
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INTRODUCTIONS
P3
WHAT DO YOU WANT TO MAKE
SURE WE COVER TODAY?
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Session Objectives
Discuss the epidemiology of diagnostic error
Describe how cognitive biases contribute to diagnostic error
Apply a specific tool to analyze diagnostic errors
Identify methods to minimize errors in diagnosis in the clinical setting
P5
#IHI27FORUM
Agenda
Definition and Impact of Diagnostic Error
Causes of Diagnostic Error
Cognitive Errors/How Doctors Think
Solutions
P6
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What is a diagnostic error?
P7
Graber Definition
A diagnosis that, on the basis of the
eventual appreciation of more definitive
information, was
Unintentionally delayed, or
Wrong, or
Missed altogether
P8
American Journal of Medicine 165 (13) 2005
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Singh Definition
The occurrence of a missed opportunity
to make the correct diagnosis in a more
timely manner
P9
Jt Comm J Qual Patient Safety 40(3): 2014
IOM Definition
The failure to
Establish an accurate and timely explanation of
the patient's health problem(s) or
Communicate that explanation to the patient
P10
Communicate Diagnosis
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A couple of cases
Split into small groups
Determine
Was this a diagnostic error?
P11
Was this a diagnostic error?
Seems straightforward, but
Requires clinical (diagnostic) expertise
Subjective
Recreating the context is impossible
Limited cognitive insight
Hindsight bias
P12
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How important is diagnostic error?
Prevalence
Impact
P13
How Common is Diagnostic Error?
Overall, likely rate of diagnostic error is
about 10-15%
Error rate varies by specialty and study
Anatomic pathology 2-5%
ED up to 12%
Medical admitting diagnosis ~6%
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Ambulatory Medicine
Examined frequency of diagnostic error via
triggers
5% of all outpatient visits associated with a
diagnostic error
50% of these with potential to cause serious
harm
12 million Americans affected annually
JAMA Internal Medicine 173 (6): 2013
Pediatrics and Diagnostic Error
45% of pediatricians report making a
harmful diagnostic error at least once or
twice a year
5% of pediatric admissions subject to
diagnostic error
Pediatrics 126 (1) 2010
Int J Qual Health Care , July 2014Pediatrics 126 (1) 2010
Int J Qual Health Care , July 2014
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What does the IOM say?
“It is likely that most of us will
experience at least one diagnostic error
in our lifetime, sometimes with
devastating consequences.”
17
How important is diagnostic error?
Prevalence
Impact
P18
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Do these errors matter?
Account for up to 17% of adverse events
40,000-80,000 US hospital deaths per
year attributable to diagnostic error
5% of all autopsies show a lethal
diagnosis that could have been treated
ante-mortem
JAMA 2002; 288:2405/JAMA JAMA 2002; 288:2405
What do these errors look like?
Diagnosis Missed on initial
evaluation
Stroke 9%
Sub-arachnoid
hemorrhage
5%
Pulmonary Tb 45%
Acute Coronary
Syndrome
2-3%
Appendicitis 19%
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Do these errors matter?
Account for up to 17% of adverse events
40,000-80,000 US hospital deaths per
year attributable to diagnostic error
5% of all autopsies show a lethal
diagnosis that could have been treated
ante-mortem
Tort claims data
JAMA 2002; 288:2405/JAMA
VA Tort Claims 1988-2000
Type of Error Number of
Claims
Amount Paid
Surgery-related 2625 $77,000,000
Medication-related 1309 $27,000,000
Diagnostic 2477 $93,000,000
J Law Med Ethics 2001; 29:335-345J Law Med Ethics 2001; 29:335-345
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Closed Claims Review
Type of Error Total Claims
Surgery 29%
Obstetrics 24%
Diagnosis 29%
Medication 18%
NEJM 2006; 354:2024-33NEJM 2006; 354:2024-33
NPDB Review
Reviewed 25 years of claims
350,000 total claims
Diagnostic error
Leading cause of claims (29%)
Highest proportion of pay-outs (35%)
More often resulted in death (40%)
25 year sum cost of $38 billion
Median cost per claim of $213,000
BMJ Quality and Safety 2013BMJ Quality and Safety 22: 2013
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Claims Paid
Costs related to-inappropriate/unnecessary testing-delayed evaluation-patient dissatisfaction
How important is diagnostic error?
Prevalence
Impact
P26
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Causes of Diagnostic Error
P27
P28
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A CASE
P29
Causes of Diagnostic Error
Three general categories of diagnostic
error
“No Fault”
Very unusual presentations, patient-related
error
Systems-related
Technical failure, organizational issues
Cognitive errors
Faults in knowledge, data gathering, information
processing or affective issues
American Journal of Medicine 165 (13) 2005
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Systems-related Errors
Technical Failures
Faulty test or data
Organizational Failures
Poor coordination of care
Inadequate supervision of trainees
Poor communication
External interference
Causes of Diagnostic Error
Three general categories of diagnostic
error
“No Fault”
Very unusual presentations, patient-related
error
Systems-related
Technical failure, organizational issues
Cognitive errors
Faults in knowledge, data gathering, information
processing or affective issues
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Basis of Cognitive Errors
Cognitive Errors
Faulty knowledge
Faulty data gathering
Faulty synthesis
Affective error
Basis of Cognitive Errors
Cognitive Errors
Faulty knowledge
Faulty data gathering
Failure to ask or look
EMRs
Faulty synthesis
Affective error
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Basis of Cognitive Errors
Cognitive Errors
Faulty knowledge
Faulty data gathering
Failure to ask or look
EMRs
Faulty synthesis
Affective error
Basis of Cognitive Errors
Cognitive Errors
Faulty knowledge
Faulty data gathering
Faulty synthesis
Premature closure
Misjudging the importance of a finding
Faulty context generation
Affective error
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Basis of Cognitive Errors
Cognitive Errors
Faulty knowledge
Faulty data gathering
Faulty synthesis
Affective error
Metacognitive failure
Causes of Diagnostic Error
Three general categories of diagnostic
error
“No Fault” (7%)
Very unusual presentations, patient-related
error
Systems-related (19%)
Technical failure, organizational issues
Cognitive errors (28%)
Faults in knowledge, data gathering, information
processing or affective issues
46%
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Arch Intern Med 2005;165:1493-1499.
Cognitive Errors/How Doctors Think
40
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P41
P42
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P43
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We think in 2
ways: Fast
and Slow
Brooks, David. The Social Animal. 2011 Random House.Horsey, Richard. The Art of Chicken Sexing. UCL Working Papers in Linguistics 14 (2002)
Chicken-sexing: Type 1 reasoning
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What are these people feeling?
Kahneman, Thinking, Fast, and Slow.
Features of ‘System 1’
Fast
Effortless
Largely below the level
of consciousness
Usually accurate but
prone to systematic
biases
Does not understand
statistics or logic
Unable to be turned off
Kahneman, Thinking, Fast, and Slow.
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Vulcan logic: Type 2 reasoning
17 x 24 = ?
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Features of ‘System 2’ Slow
Effortful
Accurate
Avoided by the
‘cognitive miser’
Makes you feel like
this:
17X24????Muscles tense, HR increases, BP
increases, pupils dilate
Kahneman, Thinking, Fast, and Slow.
Diagnosis: Chicken-sexing or vulcan logic?
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We are all chicken-sexers
(with Vulcan potential).
The interaction of system 1 and system 2
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Croskerry P, A Universal Model of Diagnostic Reasoning. Academic Medicine, Vol. 84, No. 8 / August 2009
Croskerry P. Clinical Cognition and Diagnostic Error: Applications of a dual process model of clinical reasoning. Adv in Health Sci Educ (2009) 14:27–35
Pattern Recognition
Unconscious activation of the correct diagnosis
based on prior experience.
Effortless, quick
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Heuristics
Shortcuts or “rules of thumb” that are learned
“on the job”
Quick, practical, and usually adequate
> 60 different heuristics have been described
in medicine
Classic example- representativeness heuristic:
If it looks like a duck, quacks like a duck…
Kuhn GJ. Diagnostic Errors. Academic Emergency Medicine. 2002; 9:740-750.Redelmeier DA. The Cognitive Psychology of Missed Diagnoses. Ann Intern Med 2005; 142Croskerry, P. Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias. Acad Emerg Med. 2002; 9
It’s usually a duck…, but not always.
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Illness Scripts
Stored mental model for a particular diagnosis
‘Script’ is composed of the predisposing conditions,
pathophysiologic cause, and clinical manifestations of
the disorder
Diagnosis involves mentally scanning for the illness
script that most closely resembles the clinical
presentation
Bowen JL. Educational Strategies to Promote Clinical Diagnostic Reasoning. N Eng J Med 2006;355:2217-2225.
Illness script for epidural abscessP60
Risk Factors:-Immunodeficiency
-IV drug use-Spinal surgery
-Diabetes
Pathophysiology:-Hematogenous vs. local
spread-Compression of cord-Staph aureus most
common
Clinical manifestations:-Back pain
-Fever-Malaise
-Radiculopathy-Bowel/bladder
dysfunction-Paraplegia/paresis
-Sepsis
Chao & Nanda. Am Fam Physician 2002
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We are all chicken-sexers
with Vulcan potential.
A Quiz
(Eight seconds per question;
write down your answers)
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A bat and a ball cost $1.10 in total. The
bat costs $1.00 more than the ball.
How much does the ball cost?
If it takes 5 machines 5 minutes to make 5
widgets, how long would it take 100
machines to make 100 widgets?
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In a lake, there is a patch of lily pads.
Every day, the patch doubles in size. If it
takes 48 days for the patch to cover the
entire lake, how long would it take for the
patch to cover half the lake?
Lunch Break66
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A bat and a ball cost $1.10 in total. The
bat costs $1.00 more than the ball.
How much does the ball cost?
If it takes 5 machines 5 minutes to make 5
widgets, how long would it take 100
machines to make 100 widgets?
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In a lake, there is a patch of lily pads.
Every day, the patch doubles in size. If it
takes 48 days for the patch to cover the
entire lake, how long would it take for the
patch to cover half the lake?
Correct answers:
5 cents
5 days
47 days
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Frederick S J Econ Perspect 2005
System 1 Failures- Cognitive and
Affective Biases
AKA “Cognitive Dispositions to Respond”
Over 100 cognitive and affective biases
have been identified
Croskerry P, A Universal Model of Diagnostic Reasoning. Academic Medicine, Vol. 84, No. 8 / August 2009
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How fast were the cars going when they bumped into each other?
How fast were the cars going when they smashed into each other?
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Framing effects (framing bias)
The manner in which a case is presented
(framed) influences subsequent thinking
about the case
P75
Croskerry. Acad Emerg Med. 2002
Write down the last 2 digits of your SSN
P76
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How much would you pay for this bottle of wine?
P77
Crisp and vibrant, gaining lift to the structure from acidity and fine tannins, with dark berry and coffee flavors. Lingers pleasantly. Rating: 87 - Wine Spectator
Anchoring
Relying too heavily on initial impressions
and failing to adequately adjust in light of
new information
“You never get a second chance to make a
first impression”
P78
Croskerry. Acad Emerg Med. 2002
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79
Confirmation bias
The tendency to look for evidence that
confirms our suspicions and ignore or
misinterpret data that does not
P80
Croskerry. Acad Emerg Med. 2002
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More fun with wine…
Which bottle of wine do wine club members rate as the best tasting?
$13 $90
Think, pair, share…
Refer back to the case
Think about any examples of framing,
anchoring, and confirmation bias that
occurred in this case
Turn to someone next to you and discuss
Share as a group
P82
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PREMATURECLOSURE
FRAMING
CONFIRMATION BIAS
ANCHORING
The cognitive cascade
Diagnosis Momentum
Tendency for a particular diagnosis to become
established without adequate evidence.
The farther along it gets, the more momentum it
has and the less likely anyone is to question the
diagnosis.
Croskerry. Acad Emerg Med. 2002
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Premature closure
Concluding that a patient has a particular
diagnosis before there is actually enough
evidence to make that diagnosis
Premature closure tends to stop any further
thinking about the diagnosis
Croskerry. Acad Emerg Med. 2002
Croskerry P, A Universal Model of Diagnostic Reasoning. Academic Medicine, Vol. 84, No. 8 / August 2009
Croskerry. Adv in Health Sci Educ (2009) 14:27–35
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P87
Think, pair, share…
Refer back to the case
Think about how the provider’s
affect/emotional state(s) may have
influenced their decisions
Turn to someone next to you and discuss
Share as a group
P88
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Croskerry P, A Universal Model of Diagnostic Reasoning. Academic Medicine, Vol. 84, No. 8 / August 2009
Croskerry. Adv in Health Sci Educ (2009) 14:27–35
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System 2 failures are caused by:
Inattentiveness
Distractions
Fatigue
Time pressure
Incomplete information
Cognitive “miserliness”
Croskerry P, A Universal Model of Diagnostic Reasoning. Academic Medicine 2009
“System 2 approaches can be employed by well-rested, well-sleptdecision makers under conditions in which there are no distractions or untoward intrusion of affect and all the required data are available.”
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Creating better diagnosticians
Teach trainees about the diagnostic
process
Make system 1 more accurate
Activate system 2 more frequently
P99
Croskerry P, A Universal Model of Diagnostic Reasoning. Academic Medicine, Vol. 84, No. 8 / August 2009
Croskerry P. Clinical Cognition and Diagnostic Error: Applications of a dual process model of clinical reasoning. Adv in Health Sci Educ (2009) 14:27–35
Teach trainees about the diagnostic processMetacognitionCognitive debiasing
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Croskerry P, A Universal Model of Diagnostic Reasoning. Academic Medicine, Vol. 84, No. 8 / August 2009
Croskerry P. Clinical Cognition and Diagnostic Error: Applications of a dual process model of clinical reasoning. Adv in Health Sci Educ (2009) 14:27–35
Make system 1 more accurateExperience mattersProgressive problem solvingFeedback on diagnostic decisions
Croskerry P, A Universal Model of Diagnostic Reasoning. Academic Medicine, Vol. 84, No. 8 / August 2009
Croskerry P. Clinical Cognition and Diagnostic Error: Applications of a dual process model of clinical reasoning. Adv in Health Sci Educ (2009) 14:27–35
Activate system 2 more frequentlyCognitive forcing strategiesChecklistsExpertise development
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103
SOLUTIONS
P104
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What are you doing at your
institution to improve diagnosis?
P105
National Academies Report Goals
Facilitate more effective teamwork in the diagnostic process – HC professionals, patient, families
Enhance HC professional education and training in the diagnostic process
Ensure health information technologies support the diagnostic process
Develop and deploy approaches to identify, learn from, and reduce diagnostic errors in clinical practice
Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
Medical liability, payment system, research funding
P106
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National Academies Goals
Teamwork
Education and Training √
Health Information Technology
Learn from Diagnostic Errors √
System and Culture
P107
P108
Sources: Nam, tem re commos nonsero et aut doluptas et fugitature cus nest, to im consequ oditate mpelis consent peribussenis quis eumquat ecestet aped que eos moloremque moluptatus eossi a porrovitatis experferum quae vid quo et accaborumillaborro comnientio quos dolorum eariae int volo tem quunt.Itatem qui con rem acerion sequae. Et remqui consect otatatis
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National Academies Goals
Teamwork
Education and Training
Health Information Technology
Learn from Diagnostic Errors
System and Culture
P109
P110
Patients are Members of the Team!
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Velma Payne, DEM conference 2014
Recruited 35 patients and family members
Patient Stereotyping
Labelling
Assumed Mental Health Issue
Lack of Respect
Not Listening to Patients
Dismissive of Patient Views
Resident Supervision
P111
Sir William Osler
"Listen to your
patient, he is
telling you the
diagnosis"
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What about the role of nurses?
P113
Christine Goeschel, AVP Quality
MedStar Health
P114
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Christine Goeschel, AVP Quality
MedStar Health
P115
Support interprofessional and intra-
professional teamwork in the
diagnostic process
P116
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Diagnostic Management Teams
Vanderbilt – Michael Laposata
P117
P118
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National Academies Goals
Teamwork
Education and Training
Health Information Technology
Learn from Diagnostic Errors
System and Culture
P119
KP Safety Nets, since 2009P120
Sim JJ et al, Am J Med; 128:1204-1211, 2015
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121
Sim JJ et al, Am J Med; 128:1204-1211, 2015
Larry Weed
“…minds are constrained in two ways that no
training can overcome: limited capacities for
information retrieval and processing, plus
heuristics and biases built into human
cognition…. It is pointless for diagnosticians
to try to recognize and overcome their
cognitive limits and vulnerabilities. The point
is not to overcome these human constraints
but to bypass them altogether….”
P122
Weed LL and Weed L, Diagnosis 2014; 1(1):13-17
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The Potential of Technology
Clinical Decision Support
Automated Handoff Tools
Integrated Health Record
P123
National Academies Goals
Teamwork
Education and Training
Health Information Technology
Learn from Diagnostic Errors
System and Culture
P124
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Modified Graber Checklist
Obtain a complete history
Perform a complete but focused exam
Use a systematic approach to obtain diagnostic
possibilities to be considered
Take time to pause and reflect (SAFER)
Be a skeptic
Ely JW et al, Academic Medicine 2011;86(3):307-13
Ely JW, Diagnosis 2014;1(1):131-34
Winters BD et al, Academic Medicine 2011;86(3):279-81
Diagnostic Checklist in Action
126
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Diagnostic Checklist
SAFER
Serious diagnoses
Alternative diagnoses
Feelings affecting thinking
Extraneous data…is it really
extraneous?
Reasons why this happened
Diagnostic Pause Exercise
Please form groups of 2 or 3 people
Read the exercise handout
One person take the role of attending and
lead the group through the SAFER
checklist
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CULTURE
P129
#IHI27FORUM
Psychological Safety
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Pediatrics, 2015
Diagnostic Performance
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Procedural Performance
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Solutions
Teamwork
Education and Training
Health Information Technology
Learn from Diagnostic Errors
System and Culture
Diagnostic Environment
P135
Wrap Up
Review Goals of the day
Questions
Follow-up
136
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First Year Medical Student
https://www.youtube.com/watch?v=V8l8_G_ce_Q
P137
Diagnosis Celebration
https://www.youtube.com/watch?v=rRBq-
6lVxzU&feature=related
P138