Thanks to @JamesPrattACP for pointing out this great video! Apologies if you're not a geek like me; ask your kids. It makes me wish we had someone waving red flags at us as we talk to patients.
How important are red flags to your practice? Despite the continuing negative press aimed at the NHS 111 service I think if we were on the phone hearing a patient describing the ''worst headache ever that came on quickly'' I very much doubt many of us would advise the patient to wait to see their GP. Red flags exist for a reason. They can point out the obvious as Watto is doing to Qui-Gon. Unlike Qui-Gon we should listen.
''Listen to your patient, he is telling you the diagnosis" - William Osler
I'd imagine every healthcare worker has stories of patients that act as a reminder to be humble and open minded. These cases can form our reflective practice, our teaching and help make us better at what we do if we handle them properly. We've all seen the horror stories often misrepresented in the press but if we follow red flags we can practice safely; it's not about fear it's about doing the best for our patient. It's also about being up to date. For example through safety alerts from the Royal College of Emergency Medicine or Trauma Audit and Research Network data I know I have changed my approach to elderly patients presenting with abdominal pain or a fall. On the other hand work such as the MACS decision rule challenges long held clinical convention that 'cardiac sounding chest pain' is always crushing, central and radiates to the left hand with pins and needles.
There is an interesting paper joint written by a conference of the Royal Collage of Physicians and British Geriatric Society which I recommend reading that takes a systems based approach to red flags. I think that's a very useful tactic when teaching history taking; by learning red flags and the reasons behind cardinal symptoms we improve our focused history taking and handovers.
I enjoy teaching on the Enhanced Clinical Skills course run by @JamesPrattACP on which I do a session on red flags and clinical bias. It is refreshing as someone who exists in the bubble of Emergency Medicine to see the perspective on red flags from community nurses in a variety of specialties; from general practice to psychiatry. Due to the sheer breadth of presentations in the community there are some great primary care orientated resources based on red flags. There's often reminders of how my work might have blunted my own perspective such as when I mention haemoptysis and the community based audience all diagnose cancer when pulmonary embolism was actually foremost in my Emergency Medicine biased mind!
In this session I discuss the inherent biases we all carry. Some can be unavoidable but we can and need to be aware of them; I use the example of 'the dress' for this as it also works as a good ice breaker.
We explore different sorts of biases through some, exaggerated, hypothetical scenarios. Yes, there's some cliche (the horse vs zebra conundrum is unavoidable) but I hope through the session to get our students to explore their own pre-conceived approaches to common clinical conditions as well as facing up to clinical decision making biases.
Whilst all important I find two in particular challenge us day to day.
- Psyche-out error: as far as I'm aware mental illness doesn't protect a patient from medical illness
- Diagnostic momentum: giving too much value to a diagnosis made by other professionals and not challenging it when the evidence points otherwise
Knowledge of potential biases as well as insight into our limitations helps make us safer in our practice. As best explained from former US Defence Secretary Donald Rumsfeld it's all about those unknown unknowns!
Here is a recording of my session on red flags and clinical biases recorded in front of an audience of community and hospital nurses. I have edited out some of the group work sessions for brevity.