It’s really important to structure your thought processes when studying for the exam or working on the floor in ED. The process of thinking about how you think is called metacognotion. Understanding metacognition is essentially what the acem Exam, and patients on the ed floor, tests in a rigorous and sometimes unforgiving way – how does a good ED Physician think …

This blog will be updated regularly with good strategies for thinking under pressure.

Administration or troubleshooting scenarios

Personnel ( doctor, nurse etc)
Patient ( characteristics, medical history etc)
Disease Process ( is it getting worse, complications etc)
Equipment ( ventilator failure, lead misplaced etc)
Environment ( how busy is the ed / regional vs tertiary)

Generating valid Differential Diagnoses

There are multiple strategies for this key skill in medicine, but here is my take on things:

Diagnostic reasoning is a process difficult to study – it’s a fluid organic process that gets better with age, experience and exposure to more complex and difficult scenarios.

A Process Sieve/ sorter could include :

C – congenital
H – hormonal / endocrine / metabolic
I – infective / inflammatory
N – neurological
N – neoplastic
P – psychogenic
A – autoimmune
R – respiratory / renal
V. – vascular
O – ortho
S- social / sexual
T – trauma / toxin
D – drugs

CHINNPARVO STD – was a mnemonic I created at Med school when I knew very little and it’s stuck with me for 20 years !

SYNDICATE is one I have seen used in Oz.

Create your own pathophysiological sieve.

A second option to use or combine is an anatomical approach:

Head / cns
Spinal cord
Git – oesophagus stomach duodenum
Liver pancreas gallbladder
Small and
Large bowel
Bladder GUt
Sexual organs / reproductive
Muscles / bones and nerves.

The neuro system is particularly difficult and a good approach includes the following :

Upper motor neurone
Lower motor neurone
Motor cortex – homonculus
Sensory cortex
Wernickes and Brocas speech areas
Cerebellar disease
Pond and midbrain lesions
Basal ganglia systems ( Parkinson’s etc)

Medulla and resp Centre

Spinal cord and it’s architecture
Spinothalamic tracts (sensory from cord to brain)
Corticospinal tracts ( motor from homonculus to spinal to muscle)
Posterior columns ( proprioception)

Peripheral nerves
Motor end plate