Hoofbeats: Hyponatremia Consult Case

Core IM

Clinical reasoning has traditionally been regarded as a cognitive process, however, it is also a contextually situated activity. Many contextual and environmental factors affect our cognitive load and reasoning approach. In addition, academic training often promote routine expertise where someone effectively uses sophisticated knowledge-memory structures to solve routine problems. In this episode of Core IM, the team will discuss a different kind of expertise as they explore adaptive expertise in Hoofbeats: Hyponatremia Consult Case.

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  1. Reasoning is not just a cognitive process, but also a contextually situated activity. We do not reason in a vacuum. Unfamiliar environment, ambiguous clinical questions, relative domain expertise, emotional interference, personal comfort level of the case are examples of many contextual factors that can add to one's cognitive load AND alter their reasoning approach.
  2. Situation awareness is something that precedes, prepares, and  鈥減rimes鈥 our mode of thinking and is largely affected by a person鈥檚 goals and expectations. Having clearly defined clinical goals is crucial to effective reasoning.
  3. When someone needs to operate with insufficient domain knowledge, there is the natural tendency to slow down AND to deploy different reasoning strategies such as backward reasoning. The process can be deliberate or completely unintentional.
    1. A clinician employing 鈥hypothesis-driven reasoning鈥 (鈥渨orking backwards鈥) starts with a clinical problem, generates a series of hypotheses about the patient鈥檚 illness, then tests each of these against the available clinical data. It is a time and effort consuming process.
    2. How rigorously one deploys such a strategy is often not dependent on the person鈥檚 actual expertise but rather their perceived familiarity of the problem. 鈥Cognitive ease鈥 refers to the phenomenon when we face a common diagnosis or symptom, the impression of familiarity can create a false sense of ease, which makes us more susceptible to diagnostic errors.
  4. Adaptive expertise entails someone鈥檚 ability to use existing clinical knowledge structures to come up with a novel solution when they face a complex, unfamiliar problem. An adaptive expert tends to have a solid knowledge structure of their own domain, is not satisfied by complacency, and is cognitively ready to brace novel knowledge in an unknown territory.


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Carbonell KB, van Merrienboer JJG. Chapter 12: Adaptive Expertise. In: Ward P, Schraagen JM, Gore J and Roth EM, ed. The Oxford Handbook of Expertise. Oxford University Press, 2018. DOI: 10.1093/oxfordhb/9780198795872.001.0001

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Sandhu G, Ramaiyah S, Chan G, Meisels I. Pathophysiology and management of preeclampsia-associated severe hyponatremia. Am J Kidney Dis. 2010;55(3):599-603. doi:10.1053/j.ajkd.2009.09.027

Pu Y, Wang X, Bu H, Zhang W, Lu R, Zhang S. Severe hyponatremia in preeclampsia: a case report and review of the literature. Arch Gynecol Obstet. 2021;303(4):925-931. doi:10.1007/s00404-020-05823-9

Rotem R, Bilitzky A, Abady Nezer T, Plakht I, Weintraub AY. Clinical and laboratory markers in the recovery from severe preeclampsia. Pregnancy Hypertens. 2017;8:46-50. doi:10.1016/j.preghy.2017.03.003

Mylopoulos, M, Kulasegaram, K, Woods, NN. Developing the experts we need: Fostering adaptive expertise through education. J Eval Clin Pract. 2018; 24: 674鈥 677.



John Hwang, MD - Author / Host

Cindy Fang, MD - Author / Host

Aron Mednick, MD - Author / Expert discussant

Shreya Trivedi, MD - Author / Producer


Sean Burke, MD

Vickie Kassapidis, MD

Those named above, unless otherwise indicated, have no relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Release Date: January 28, 2022

Expiration Date: January 28, 2025

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