So You Want To Rock Your Rotation?

 This post by Dr. Margaret Goodrich is a one stop guide to excelling on your EM Rotation. In this very weird year, impacted by the COVID pandemic, you may only get to do one EM rotation. Make it count.

Professionalism

While some of this may seem redundant to what you’ve been told in the past, sometimes it just needs to be
said again. While your clinical knowledge is part of your evaluation, another major part is HOW you do the job
and your interactions with others. 

Be punctual

The old adage of “if you’re on time, you’re late”. This applies to shifts, conferences, SIM, workshops, meetings… basically everything. Plan for travel time, figuring out where you’re supposed to be, parking, etc.

Dress for success

Thankfully in the ER that means clean scrubs and close-toed shoes. Depending on the rotation, they may have a dress code for conference/didactic sessions. Whatever it is, respect it. It is worth bringing a business casual outfit (or two) and even a suit (some will interview you while you’re there).

Attitude

Come in to work ready to work! This is a job that demands you be “on” the entire shift. Be ready for that.  Show that you are excited to be on your rotation, in the department and working alongside potentially future colleagues. Your attitude will affect those around you. Think about what kind of influence you want to be.

Take Initiative

This shows that you want to be there and want to learn in the ER. Each program is different with how they get you involved in patient care (will have you just sign up and see them, will direct you towards patients), get a sense of this then find ways to be proactive about it. However, even if you know how to do a procedure, DO NOT just start doing it without talking to your resident/attending. Touch base with them, let them know you’re willing to do it and ask how they would like for you to proceed.

Be Inquisitive

This job is ALWAYS changing and there is always something to learn, especially early on. When you’re thinking about a patient’s care, ask “what else?”

• What else should be on my differential?
• What else could be an intervention?
• What else could be part of this work up?

Find something that was interesting on each shift, then go home and learn more about it. A chief complaint,
an intervention, a procedure, etc.

Respect

Be courteous to those you interact with (residents, attendings, program coordinators, nurses, techs,
secretaries, cleaning staff, patients, families… LITERALLY EVERYONE). Believe me, it will be noticed
if you are rude to someone. The value of “please” and “thank you” cannot be understated

Honesty

Be open and honest with your senior resident/attending. If you haven’t done something before, THAT IS FINE! It would be unrealistic to expect that as a medical student you are proficient at many EM skills. That’s the whole point of residency. It is UNACCEPTABLE to lie to your senior/attending about your skill level. If you haven’t done it, just say so. Then demonstrate that you are eager to learn about it (YouTube is great to find a quick video, or check out this website: https://www.emra.org/students/advising-resources/skill-demonstration-videos-and-topics-pertaining-to-em/ ) and be prepared to try!

Effective Communication

This is going to be paramount throughout your career. Now is a great time to continue working on it!

Who’s who?

Make an effort to learn the names of the people you work with. It will take time, but it makes communication
more personal, easier and more direct.

Closed loop communication

Make sure the person you’re talking to actually knows you’re talking to them (using names is really helpful
here), they hear what you want, and verbalize that they understand what you want them to do.

Example: “Joe, please get an EKG on Mr. Smith.” “Ok Doctor, I will get an EKG on Mr. Smith.”

This ensures that the other person is aware an action needs to get done. It also provides them with an opportunity to tell you that it is beyond their scope of practice or that they are not able to perform that now. Which means that you can find someone else to get it done and not wonder why it hasn’t been done after an hour.

This is not only important for general patient care, but imperative for resuscitations/trauma/high acuity
patients when things can become chaotic quickly or the patient requires a number of interventions
simultaneously.

Respect

We already mentioned it, but it’s worth mentioning again.

Feedback

How to make the most out of what your preceptors are telling you!

Blind spots

We all have them. Feedback from your preceptors is a great way to discover areas that you need work on
that you weren’t aware of.  Make note of these somewhere (on your phone, a physical notebook, stone tablet, whatever), then evaluate how you can work on them.

Setting up your shift for feedback

Some preceptors are more conscientious about giving feedback than others. To help you get feedback, decide something specific that you want to work on before your shift. Once you arrive, tell your preceptor what you would like to work on and ask them for feedback on it at the end. This does two things:

1. It makes you be cognizant of a specific goal for the day rather than “get better”
2. It sets up your preceptor to know that you are actively looking for feedback and that they should be keeping in mind your goal for the day. It helps them to give more direct feedback rather than “nice job”

But what if I don’t like the feedback?

Inevitably, you’re going to get feedback you don’t like/rubs you the wrong way at some point. We’ve all
been there. When this happens, our natural response is to get defensive. Take a minute, think about
why you’re getting that feedback. Is there something that you didn’t realize before (blind spot)?
What can you do to fix it?

What do I actually do with the feedback?

Attempt to make an active change. There is no point in getting feedback if you don’t make an adjustment.
If it is in the middle of shift and it’s something that could be done on your next patient encounter, try to
do it then. If it’s the end of shift, consider it as your goal for your next shift or for the topic that you’re going to learn
about before next shift.

During Shift

The art of actually doing things.

Workflow

Starting to develop good habits now can help you as you start residency. Below is a general outline for
ED workflow:

STEP 1: Pick up a patient. This will vary by institution. Touch base with the senior resident/attending to see if there is anyone to see and ask them how they would like for you to see new patients throughout the day. Wait for them to tell you? Pick up new patients on the board? Ask them each time a new patient is available?

STEP 2: QUICK chart evaluation, review documented vital signs (if available). Do NOT wait 15 minutes to go see the patient. If you’re picking them up you should be ready to see them shortly.

STEP 3: Actually see the patient, do your HPI and exam. *IF AT ANY POINT you have concerns about vital signs, mental status, a specific exam finding that would require EMERGENT attention, quickly excuse yourself from the room and find your preceptor.* You will not be faulted for grabbing preceptors sooner rather than later if you’re concerned about the patient.

STEP 4: Develop your differential and management plan. There are a number of different mnemonics but one that I like is SPIT:

• Serious - all the big bad terrible things that as an ER doc you need to at least consider
• Probable - while you have to consider all the terrible things, what do you actually think is going on
• Interesting - what’s the zebra diagnosis to consider?
• Testing/treatment - what labs, imaging, medications, fluids, etc would you want to help you evaluate and treat the patient?

Your preceptors will usually want the serious differential items FIRST, but also include the other items on your differential as well.  Know that your management plans are not going to be perfect. That’s part of learning. You will learn more by developing a plan and presenting it then discussing with your preceptor why they agree or disagree. If you simply wait for them to develop the plan for you, you won’t learn as much.

STEP 5: Follow up on testing. It’s always great if you know the results before the preceptor. Think about what the results mean (even if they are normal/reassuring), and what the next steps would be.

STEP 6: Reassess the patient. If the patient has received an intervention, how are they doing after that? Is there something else you want to do as an additional intervention?

STEP 7: Determine what you think the disposition is. This is helpful to think about after your first encounter with the patient because it helps you to get a sense of where the visit is headed. Obviously things change, but it will help to try and get a sense of: sick or not sick? Going home or getting admitted? Is there a safety reason why they shouldn't be discharged (like social work or case management needs)?

Procedures

There will likely be some opportunity to do procedures during your rotation. Again, this will depend on the institution and your preceptors. Be eager and willing, but as stated above DO NOT LIE ABOUT YOUR ABILITIES/EXPERIENCE. If you haven’t done it before, inform your preceptor, preferably not in front of the patient.

Find a resource to help you learn how to do procedures that you haven’t done before, like this website: https://www.emra.org/students/advising-resources/skill-demonstration-videos-and-topics-pertaining-to-em/

Know the indications, contraindications and technique of the procedure. Ask for help if you need it.

Notes

This is incredibly institution dependent. Some will allow you to write notes, others will not. If you are allowed to write notes, certainly do your best with it. You should get more instruction from the institution on what your specific duties are

Daily goal

Determine what you want to work on for the day. It’s more helpful if it’s specific, rather than “get better”. Inform your preceptor of what you’re working on for the day.

Presentations

This is something you will be doing throughout the rest of your career (think about admitting patients,
consultants, etc.). In the ER, we do more focused presentations than on other services.
Look at this website: https://www.emra.org/students/advising-resources/patient-presentations/ 

Dr. Margaret Goodrich is a Medical Education Fellow at UMMS-Baystate Department of Emergency Medicine and an expert on excelling as a learner in EM.

Guide to Sub-Internship Success - Be a Rotation Rockstar

[This guest post is a guide to succeeding on EM rotations by Dr. Duncan Grossman, a first year resident at Maimonedes Medical Center in Brooklyn, NY.  Originally created for his fellow EM bound students at the University of New England, the guide has been adapted for all and is a great perspective on how to succeed on EM rotations. 

- Adam]

This guide reviews what to expect on your sub-internships and how you can look like a rockstar. I'll also include a list of resources -- some of which you *must* use, some of which will be up to you.

CHAPTER ONE -- WHAT TO EXPECT

Typically your first day will consist of some sort of orientation. You'll meet your clerkship director and other rotators, do some paperwork, maybe meet a resident or two. You'll get a tour of the ED and they'll set some sort of outline about what to expect for your four weeks. They'll mention SLOEs this day too, probably -- since you're rotating during prime SLOE months, they kind of already know you want one.

You'll work a variety of shifts. These may include nights, fast-track, shifts on the ambulance, or any combination.

Remember, you're at a residency program, so there are weekly lectures for the residents that you'll attend. In addition, you may have specific med-student lectures. During these they may do skills labs (central lines, splinting, lumbar punctures), SIM labs, and they may have you do a presentation. Don't stress about presentations -- no one is looking to eviscerate you, just to see that you put some effort in and learned something.

Some places have a test on the last day. Some don't.

Most places will offer you a guaranteed interview at the end. Some will not.

CHAPTER TWO -- ON SHIFT

Consider listening to a podcast or quickly reviewing a topic on your way in, just to get in the mindset.

The hardest part of these rotations (in my opinion) is that you'll likely be paired up with a new attending for every shift. That means you need to establish rapport and trust at the beginning every single time. Don't get lazy with your appearance or enthusiasm -- remember, you are always auditioning.

At the beginning of the shift, introduce yourself to the attending, residents, and even to some of the nurses & techs (these people can be a gold mine of knowledge and may grab you for cool stuff). You might say something like, "Hey there, I know you're busy, but I just wanted to introduce myself: my name is Duncan and I'm your med student for today for the 7a-7p shift." 

(Pro-tip: I try to say the hours of my shift at the beginning because sometimes your attending will be working different hours, so instead of awkwardly saying no when they ask you to see a patient at 6:59pm, you set the expectation.)

If it's not crazy busy, I always try to ask, "What are your expectations of me for this shift?" This does three things. 1 -- It shows you are enthusiastic and you care. 2 -- It sets what you should be doing. 3 -- It allows your attending/resident to realize what they want out of you, so you're all on the same page.

See patients (obvs). There's a fine line between being proactive and being annoying, so ask if there's anyone to see and if your preceptor says not yet, then just chill out. Read, go walk someone to x-ray, familiarize yourself with the equipment carts -- always be doing something, even if it's small. Some places will steer you toward patients, some will tell you to sign up for them... It just depends.

Seeing patients is the fun part -- we'll address some pearls later in the email.

Once you've seen them, you need to present. We'll cover *how* to present later, but when you're ready, you should say, "Dr. Johnson, I saw the patient in room 3 and I'm ready to present whenever you're free." Sometimes you'll present immediately. Sometimes an hour later. Sometimes you'll never present it. That's just the ED for you.

Volunteer to do procedures (suturing, IVs, splinting) for all the patients, but especially your own.

**Fun Tip** I scribbled down super interesting patients and little knowledge nuggets in the back of my notebook and kept a running list through the whole rotation. It may be as simple as "Lovers Fx = b/l calcaneal fx" or a chief complaint like "central retinal artery occlusion." It could also be something for you to look up later, like, "Pics of ultrasound fetal pole."

CHAPTER THREE -- END OF SHIFT

You'll likely turn in an evaluation sheet to your preceptor at the end of your shift. (Consider doing it 30min before the end so you're not giving it to them while they're running out the door.) They know they have to do it, so you don't have to make a huge production out of it. A simple, "Dr. Johnson, can I leave my evaluation at your computer?" will suffice.

But you're NOT DONE THERE -- this is your time to shine, peeps. This is when you ask, "What can I do to be better on my next shift? What can I improve on?" This is gold on your evaluation. Be humble, don't be defensive about critical feedback, and thank them sincerely. Then thank everyone around you.

Pat yourself on the back, take a breath, and chill out.

__________________________________

__________________________________

RESOURCES

Just like studying for boards and school, when looking at this insane list of resources, find what works for you.

With that said, there are a couple of mandatory (in my opinion) resources that you need to have under your belt. I listed those under "Mandatory." Then just pick a couple from the other lists.

MANDATORY:

1) Patient Presentations -- Document

http://emergency.med.ufl.edu/files/2013/02/The-3-Minute-Emergency-Medicine-Medical.pdf 

2) Patient Presentations -- Video

https://www.emra.org/emresident/article/making-the-most-of-patient-presentations/ 

3) Clinical rules -- App (Download onto your phone!)

https://www.mdcalc.com/ 

4) Chief complaint driven guide to differentials -- *BEFORE YOU BUY* you may get this for free with an EMRA membership, which you should def get. If it's not free, I'd still recommend buying it -- it's a great resource to start organizing your thoughts with regard to chief complaints.

https://www.amazon.com/Basics-Emergency-Medicine-3rd-Ed/dp/1929854471

PODCASTS:

1) EM Basic Podcast -- 30 min episodes -- Super dry but really covers the nuts and bolts of stuff you need to know for routine emergency medicine. Listen to him on 2x speed. He also has "show notes" which are a GOLD MINE of information, and I'm actually making flashcards out of them before internship.

http://embasic.org/ 

2) EM Clerkship Podcast -- 6 min episodes -- Really short but awesome overviews of chief complaints, ddx's, procedures, etc. Good to cover a lot of info in a little time.

http://emclerkship.com/

3) EM:RAP -- Variable time -- I just started listening to this but everyone raves about it. Free with your EMRA membership. Their "C3" lectures will cover Core Clinical Content. All the rest is gravy. They have their own app.

https://www.emrap.org/

4) EMCrit -- 30-60min -- So these are pretty advanced and honestly, I don't think they're going to be particularly high-yield for your rotations. But I have friends who love it.

https://emcrit.org/

5) The Emergency Medical Minute -- 5min -- This is just a whole bunch of recordings of residents lecturing their co-residents on tiny topics. Kind of like the clerkship podcast above but less formal and tackling less core content.

https://emergencymedicalminute.com/

6) Core EM Podcast -- 20min -- Great podcast covering core content. Two hosts.

https://coreem.net/

7) PEM Playbook -- 60min -- Pure gold for pediatric emergency medicine. Listen to this if you have a couple peds EM shifts thrown in or if you're doing a PEM rotation.

http://pemplaybook.org/

BOOKS:

1) Tintinalli's Manual -- Small version of the biggest name in EM textbooks. Carried this with me in my backpack and would bring it to shift, looking up diagnoses and treatments of patients I had. Highly recommend.

https://www.amazon.com/Tintinallis-Emergency-Medicine-Manual-Eighth/dp/0071837027/ref=sr_1_1?s=books&ie=UTF8&qid=1522592440&sr=1-1&keywords=tintinalli+emergency+medicine+pocket

2) Tintinalli's Just The Facts -- I think it's physically bigger, but more succint?

https://www.amazon.com/Tintinallis-Emergency-Medicine-Facts-Third/dp/007174441X/ref=sr_1_3?s=books&ie=UTF8&qid=1522592563&sr=1-3&keywords=tintinalli

3) Rapid Interpretation of EKGs -- If you have NO IDEA where to start with EKGs, make sure you read through this.

https://www.amazon.com/Rapid-Interpretation-EKGs-Sixth-Dubin/dp/0912912065/ref=sr_1_1?s=books&ie=UTF8&qid=1522592858&sr=1-1&keywords=dubin+ekg

4) ECGs for the Emergency Physician -- A whole book of EKGs to quiz yourself.

https://www.amazon.com/ECGs-Emergency-Physician-Amal-Mattu/dp/0727916548/ref=sr_1_1?s=books&ie=UTF8&qid=1522592807&sr=1-1&keywords=ekg+emergency+medicine

5) Antibiotic Guide -- Should be free with EMRA. Used it a couple times, def not mandatory. They have an app, too.

https://www.amazon.com/EMRA-Antibiotic-Guide-Brian-Levine/dp/1929854455/ref=sr_1_1?s=books&ie=UTF8&qid=1522592924&sr=1-1&keywords=emra+antibiotic+guide+2018

APPS:

1) MD Calc, as listed above. Learn how to use PERC, Canadian Head CT, PECARN, Wells (PE and DVT), San Francisco Syncope.

2) Epocrates for drugs

3) Medscape -- good for drugs and diseases but is occasionally incorrect

4) WikEM -- a wikipedia page specifically for emergency medicine. Really great resource -- you can plug in chief complaints and it'll give you an EM specific wiki page.

5) PalmEM -- recommended to me but I couldn't justify $20 for an app. Looks cool.

VIDEOS: (My favorite, personally!)

1) EM:RAP -- Just found this. Def gonna watch these.

https://www.youtube.com/watch?v=Po7mIrOKPwc

2) EM in 5 -- This is my absolute favorite. Biased because it's done by the clerkship director at my soon-to-be-residency, but I think this is my absolute favorite resource.

https://www.youtube.com/user/aebargren

3) Emergency Medicine Cases -- These guys have a podcast too

https://emergencymedicinecases.com/rapid-reviews-videos/

Good luck out there!

-Duncan

EM Presentations 2.0

The not-so-secret "secret" of doing well on your Emergency Medicine (EM) rotations is to be able to give patient presentations the way that your supervisors want to hear them.

We have covered this in the past in a post on "The Secret to Honors", and that advice has not changed. The best way to make a good impression is with organized and focussed presentations that include a worst-first differential diagnosis and a plan appropriate to an acute care setting.  There is even a bit of literature to back-up this approach. The 3-Minute EM presentation article has been a staple of EM clerkships for years.

Some ingenious folks at the Emergency Medicine Residency Association (EMRA) and Clerkship Directors in Emergency Medicine (CDEM) have improved upon this resource with this video on Patient Presentations.  The 10 minutes invested will undoubtedly pay off on your EM rotation.

Enjoy!

Adam Kellogg is an Associate Residency Director. When he was a Clerkship Director he gave every student a copy of the 3 Minute EM Presentation.  Some of them even read it.  

So You Got a High Pass

So You Got a High Pass....

This time each year, I hear from many students that they are devastated by their grade on their first EM rotation. There appears to be a common misconception that a High Pass is a death knell. This is far from the case, we are frequently swayed to interview students who receive High Pass on their first EM endeavor. 

So why you ask, do we get excited for those who weren’t rock stars from day one? The answer is simple: If you could choice to train one of two runners, they both run the 100 in 12 seconds one with perfect form, and the other with horrible form, who do you choose? We choose the second, if you teach her good form she will beat the first.  The student who gets a High Pass on their first rotation, and Honors on the second will outdistance the rock star every time. Our great search in residency is for the teachable student. 

So what can you do to become this sought after teachable candidate? You need to improve in each aspect of EM. This is the time to be proactive; call or write the clerkship director at your first rotation, and get the specifics you need to address. 

For most this falls into two categories: 

1. Approach
2. Application

The approach for EM that is successful is proactive, energetic, and enthused. You want to go in, and light the place on fire. Be forceful, everywhere, and ahead. Run to action, put gloves on, and think what they will need next, and supply it. Never pass up an opportunity to get involved, or do even a menial task. You will be noticed and given more. Being reserved, quiet, or contemplative is likely to result in evaluations below your ability. Be willing to put your thoughts out there, and show how you can apply yourself. 

The application is realizing there are discrete skills in EM, you need to have them. The first is the EM presentation, read The Three Minute EM Presentation learn it, and do it. The second is the weighted differential, keep it wide, focused on the worst possible diagnoses, that could present like your patient, the probable reasons for this presentation, and the interesting (Zebra) that could present like this. Have this ready before your presentation, so you can amend your presentation to include the pertinent positive, and negatives for this differential. Review common EM core content, by reading texts, review books, or listen to EM basic or FOAMcast. The Plan is the last step, come up with how you will address your differential. Less is often more, don’t forget to start with your interventions for the patient, and then go to ancillary testing, that helps discriminate your differential. Now make it happen, be the first to recheck the patient, check test results, and think what you will do with the positive or negative result. 

Turn your disappointment into determination. Show us you can and will learn the form, and beat the natural. 

So EM is right for you, now you need a plan….

So EM is right for you, now you need a plan….

Step One:
Rotations
You need to do a home and an away rotation in EM as early as possible. Read the link to get all the details about choosing the right rotation.

This will give you exposure, personal advising, and feedback. It is incredibly important to do two things: 1-recognize the feedback you get, 2- demand feedback you haven't gotten in real time.

• You will get feedback on every step, of every encounter - your job is to recognize it. While you present, notice what your supervisor does: glazed eyes = too much information, confused look = add details, fidgeting = speed it up. Every supervisor will want something different and you need to continually adapt to every one that you work with. Start with a formal, organized presentation, and then edit it throughout your shift to fit the non-verbal feedback you are getting. This article gives a great architecture to start with. 
• Next you need to demand feedback. You can ask at the end of your shift, but often you will hear "you did a great job." More effective is a proactive approach. Self reflect and decide what you need to work on, then at the beginning of the shift let your supervisor know what you want to work on today. This lets them focus on the area you need help in and immediately lets them know you are open and eager for feedback and want to improve. This also allows the supervisor to note how you incorporate feedback and feed this into your evaluation. 

Step Two:
Audition

You are auditioning, you need to put your best face forward. You want to present yourself, at your best every day, and in every interaction. You want to be the worry free student, always willing to help, looking to do more, and happy to put in extra effort and time. Don't ask for special treatment, special schedules, or lots of days off. Don't call out unless you are seriously ill. Don't show up late to lectures because you stopped for breakfast.

As Amal Mattu says "be a Tigger": show up with a smile, positive attitude, and energy to spare. Be the person everyone wants to work with, especially the nurses and techs. Always be respectful, professional, and appropriate. EM tends to be a casual atmosphere, but resist the urge to be too casual. It is easy to step over the line when trying to fit in. Realize you are not in the same position as the residents or attendings and err on the side of caution. Be professional at all times. lean forward, look interested and acknowledge areas to improve.


Step Three:
The SLOE

You need to get your letters of recommendation. Your rotation is the basis for your letter, the more you can show the kind of resident you will be, the better your letter will reflect your abilities. The SLOE compares you to your peers. Your goal is to show your positive attributes and that you can grow and improve in 4 weeks. Set a time to meet with the program director and clerkship director, to discuss your interest in their program and get recommendations for your application. Set goals for yourself and meet them.

With these three steps you are well on your way to succeeding in your EM application

Communication Breakdown: Zebras, not Unicorns

In my last post I discussed the role of presentations in determining how a student is perceived by their evaluators.  Today I want to hone in on one particular part of the presentation:  the Differential Diagnosis.

The usual advice given to students on how to construct an "EM appropriate" differential is to go "worst first".  This means that the first diseases you discuss are those most likely to result in morbidity and mortality for the patient.  This is important in the ED as this is the place where all the sickest patients get funneled to.  In most out-patient settings acutely ill patients are a terrifying rarity.  In the ED they are the routine.  If you do not think of a life-threatening diagnosis, your chances of lucking into it are low.  "Worst first" is a safety net for us and our patients.

Every student has probably heard the truism, "When you hear hoof beats, think horses, not zebras."  The problem with this clever turn of phrase is that zebras are real.  If you have ever been to a zoo, or the Serengeti, you have seen them.  Positioned as we are, at the bottom of the medical pathology funnel, the ED is the Serengeti of medicine:  the place where zebras roam.  Or at least the zoo of medicine.

Not all uncommon diseases (zebras) are dangerous.  The uncommon and bad ones, like aortic dissection (~200 times less common than MI) are the ones we must be vigilant against and belong on our differentials when we "hear hoofbeats" (i.e. "chest pain").  Zebras that are not particularly dangerous do not need to appear on your differentials.

There are still diagnoses we should ignore, diseases that do not belong in an ED differential.  These are the ones that are neither common nor dangerous.  These are the ones we will only find in text books.  For EM, the truism should be changed to, "When you hear hoofbeats, do not think of Unicorns".

Once a student is able to reliably think of the dangerous zebras, the life threats, I encourage them to order their list by probability.  When first getting used to EM it is okay for your differential for a 25 year old man with pleuritic, reproducible chest pain and normal vitals to be "AMI, dissection, PE, pneumothorax, and espophageal rupture".  You have included the bad stuff.  But you have not given weight to prevalence of disease or your own clinical impression.  This is not what your supervisors are actually doing.

Instead, once you are reliably thinking of all the bad diagnoses, you can start presenting your differential the way the residents do.  Start with what you think the patient actually has, and why.  And that can be a common and less dangerous diagnosis.  You need to follow that "horse" with the less likely but more concerning differentials (the zebras), why you do not think the patient has them, and how far you want to go in tracking them down.   You can even tack a unicorn on at the end, so long as you do not want to actually pursue that mythical beast.

Happy hunting!