Always Have a Backup Plan

One lesson I learned early in my teaching career was to always have a backup plan, a “plan B”. I find that often, residents either have no backup plan or have a hard time articulating one. Having a ”plan B” is one concept that my teachers ingrained in me, that I refined, and that I see many, experienced clinicians have developed. However, I have seen few explain it in an explicit, clear and succinct manner.

Often in medicine, the situation goes a different direction than we planned. We should be asking ourselves, “what is my next step if this one doesn’t go my way?” If we’re not ready, we could be caught flatfooted and off balance, therefore slow to react to what the actual result was. This happens in both the therapeutic and diagnostic realms. Some simple examples will clarify what I mean more than abstractions.

For a diagnostic example, we have a 26 year old female patient present with waxing and waning left flank pain for 24 hours, subjective fever, and urinary frequency. She has moderate left flank tenderness. We think it’s suspicious for a pyelonephritis. If the urinalysis clearly shows UTI, we’ve clinched our diagnosis. Here’s where the concept of a backup plan comes in: What if the urinalysis is normal? What’s our next step? The answer should come out pretty quickly, because we should have thought about this possibility in the beginning. If we haven’t, we’re already a step behind.

For a therapeutic example, we have a 55 year old female patient presents with 4 days of shortness of breath and wheezing consistent with her asthma. We prescribed her oral steroids and bronchodilators 3 days ago. She took her medicine as prescribed. Today she has minimal improvement of symptoms. She can hold conversation without becoming short of breath. She has diffuse wheezing in all lung fields. We expected she would get better. Here’s where the concept of a backup plan comes in:  What’s our next step? We should already have a good idea of the next step, because we should have considered this possibility already.

For a mixed example, we have a 26 year old male patient present with 12 hours of severe, nonradiating, epigastric pain and nausea after a bout of drinking. He has moderate, epigastric tenderness. No guarding. We suspect he has alcoholic gastritis. We give him and IV H2 blocker and an IV antiemetic. There is no change in his symptoms. Here’s where the concept of a backup plan comes in: What’s our next step?

There’s not necessarily one right answer to any of these simple scenarios the way I’ve presented them. The concept applies to both diagnostic and therapeutic scenarios. However, too often, I’ve seen trainees caught flat footed by this question of what their next step is when things go differently than they planned. Sometimes I’ve seen attendings give a signout without spelling out their intended next steps if things don’t go as planned… I’ve seen a few of them caught flat footed too. All clinicians should keep this concept in mind whether they are trainees or seasoned clinicians.

If you’re interested in learning more about clinical decision making and other, related topics, please check out my book: A Guide to Clinical Decision Making.