The Med Ed Toolbox: SPIT

MedEdToolBoxGraphic

More than just a bodily fluid or a way to roast some meat…

During the past few weeks of overnights, I’ve gotten to work with a fabulous pediatric resident. He’s smart, speedy, and funny, which is exactly what you need at 3am when you’re seeing another constipated neonate. When we realized that we had LOTS of overnights together, I asked him if there were any specific education or performance goals I could help him with. After some thought, this astute resident self-identified one of his biggest strengths and weaknesses. While he could quickly identify and manage the baby with bronchiolitis, he sometimes struggled to think outside of the box and come up with a greater range of possibilities for the patient’s symptoms.

So what do you do with the learner who needs to consider a broader differential diagnosis when evaluating/presenting patients?

What was I going to do to help out this super-smart resident? Especially when I already knew that he had an excellent fund of knowledge; he just needed to access it more readily when thinking about specific patients. I was reminded of a teaching tool I heard about at the Society for Academic Emergency Medicine 2013 meeting, which is tool #2 for the med ed toolbox:

Broaden a differential diagnosis by considering SPIT causes:
Serious
Probable
Interesting
Treatable.

So how does this game work?

  • The presenter comes up with at least one unique diagnostic possibility for each letter of SPIT for the patient in question.
  • You can discuss it as part of the patient presentation or even after reviewing the triage summary before seeing the patient.
  • It can vary depending on your learner and personal style.
  • Some even have learners write down their responses on an index card prior to discussion!

Even though this seemed super cheesy and was going on in the wee hours of the morning, at times during the southern snowpocoalpyse, this resident was up for something to break up the monotony. For example, for the tachypneic, grunting, likely bronchiolitic patient, he might contribute:

  • Serious = congestive heart failure
  • Probable = bronchiolitis
  • Interesting = oil of wintergreen ingestion
  • Treatable = pneumonia

We employed SPIT consistently for a few shifts, during which we “spat” out all sorts of differential diagnoses, got really creative, and had a few laughs.  And those diseases that can seemingly do anything (ex: lupus, tuberculosis, sarcoidosis) weren’t even mentioned all that often!!!

llama

But even after the trial period, when the resident stopped announcing his formal delineation of the serious, probable, interesting, and treatable diagnoses, the resident’s differential diagnoses of his patients VASTLY improved while he got to show off his knowledge base a bit more.  Other residents took note of our silly game, and after some eye-rolling, even dared to present in a similar fashion.

Ultimately, SPIT may not be a tool for everyone and all times.  But it is a fun, silly way to push learners to consider beyond the obvious diagnosis, reach into the deep recesses of their brains, clear out a few cobwebs, and be a little creative – which is sometimes exactly what you need at 3am.

References
Original idea: Credited to Judy Paukert PhD in Medical Education
SAEM 2013: “Taking Advantage of the Teachable Moment: A Workshop for Efficient, Learner-Centered Clinical Teaching” by Todd Guth MD, Elise Lovell MD, Sneha Shah MD, Mike Epter DO  http://www.saem.org/docs/2013-annual-meeting/teachable-moment-saem-handout.pdf?sfvrsn=2
ALiEM: http://academiclifeinem.com/trick-of-the-trade-increasing-students-responses-to-the-differential-diagnosis/

By learning you will teach; by teaching you will learn. — Latin Proverb
Maneesha Agarwal

Maneesha Agarwal

Assistant Professor at Children's Healthcare at Emory
Maneesha's professional passions are medical education and injury prevention, specifically poisoning. Maneesha enjoys spending time with her large family including her hubby and crazy toddler, cheering on her Tar Heels, skiing, and baking. She is also the academic editor for Emory's PEM blog.
Maneesha Agarwal

Latest posts by Maneesha Agarwal (see all)

Maneesha Agarwal

Maneesha's professional passions are medical education and injury prevention, specifically poisoning. Maneesha enjoys spending time with her large family including her hubby and crazy toddler, cheering on her Tar Heels, skiing, and baking. She is also the academic editor for Emory's PEM blog.

6 Comments

  1. I love this! Thanks for the new trick- I’m going to try it out tonight. And the weirdest part is my daughter was rearding that exact page in the llama alphabet book yesterday. Great post!

  2. I love this! Thanks for the new trick- I’m going to try it out tonight. And the weirdest part is my daughter was rearding that exact page in the llama alphabet book yesterday. Great post!

  3. Thanks! Please let us know how it ends up working for you!

  4. Had to come back and give this 2 thumbs up. I used it several times on my Friday shift and it was a hit – especially since I was running out of ways to teach about gastro. Easily a third of the patients were there for vomiting!

  5. I am so happy to hear that SPIT is enjoying some success in other parts of the country. Thanks for the feedback and stay tuned for more Med Ed tools!

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