Kevin's Comb and Becky's Braids: A Model for Clinical Reasoning in Geriatric Medicine

As clinicians, we need to organize and use knowledge in ways that allow us to identify and manage clinical problems. Clinical reasoning is the process of sorting through a cluster of features, assigning a diagnostic label (diagnostic reasoning), and developing a management strategy (management reasoning) [1, 2]. This can be particularly challenging in the field of geriatrics, where the presentation of disease is varied and can be complicated by multiple comorbid conditions, geriatric syndromes, and normal physiologic changes of aging. Management decisions can be further complicated by limited guidelines for patients with multiple conditions, reduced access to care, minimal caregiving support, trauma histories, and variable acceptance of treatment strategies by patients and care partners [3, 4]. Conceptual frameworks can help guide our thinking, but existing frameworks do not adequately address the inherent complexity, iterative diagnostic process or practical constraints of caring for older adults [5, 6]. Kevin's Comb and Becky's Braids is a conceptual framework for clinical reasoning in geriatric medicine designed to fill this gap. It offers a structured, visual model that emphasizes an iterative, multifactorial diagnostic process—illustrated by the “comb” passing repeatedly through a tangle of interrelated signs and symptoms—and a dynamic, patient-centered approach to management planning—represented by the “braids” that weave together realistic, goal-oriented interventions responsive to the needs of both patients and their care partners (Figure 1). Diagnostic reasoning involves comparing and contrasting illness scripts, our stored mental models of disease, to develop a working hypothesis for the etiology of the presenting complaint [1]. Two common frameworks are Occam's Razor, which favors the simplest unifying explanation, and Hickam's Dictum, which reminds us that patients may have multiple concurrent diseases [7, 8]. While helpful in different circumstances, neither accounts for geriatric complexity, where comorbidities, medication effects, and aging physiology require a less reductive and more nuanced approach. The concept of the geriatric syndrome highlights how multiple pathophysiologic and iatrogenic factors contribute to a unified clinical complaint [9]. This contrasts with the concept of a single disease, which represents one pathophysiologic process resulting in various signs and symptoms. Diagnosis in geriatric medicine is less like electron microscopy and more like x-ray crystallography. Each progressive review of a symptom may tease out another contributing factor. Where one unifying diagnosis might account for presenting symptoms, multiple others may be contributing as well. Management reasoning balances disease contributions, treatment effects, resources, and patient preferences [2]. Balancing benefit and burden occurs in a context of multimorbidity, multiple geriatric syndromes, goals of care, and upstream determinants of health. In one study, care errors occurred in over 75% of contextually complicated encounters, and in more than 90% with both contextual and biomedical complexity [10]. Structured approaches can help clinicians clarify risks and benefits, prioritize steps, and avoid overwhelming patients and care partners. Studies of clinical reasoning in multimorbidity highlight the challenges of competing priorities and contextual influences [11]. Tools have been developed to aid clinical reasoning in various contexts of geriatric medicine. The Geriatric 5Ms can guide evaluation and management plans, with prompts for Medication effects and compliance, Mentation factors of mood and cognition, the influence of Mobility, what Matters most to patients and caregivers, and the Multi-complexity detailed above [12]. Similarly, management tools such as Patient Priorities Care and the American Geriatrics Society Multimorbidity Toolkit guide treatment toward patient goals while balancing interactions, benefits, and harms [13, 14]. An effective clinical reasoning conceptual framework provides the clinician with an approach to organizing their thoughts so that they can choose the best tool for the situation. We propose Kevin's Comb and Becky's Braids as a conceptual framework that creates a visual representation of complexity and guides iterative diagnostic and management reasoning. Kevin's Comb acknowledges the tangle of symptoms and signs with which patients present. The comb represents the diagnostic reasoning process which must tease out the factors contributing to common geriatric syndromes. Each pass of the comb prompts a diagnostic pause—intentionally taking a moment to question intuitive conclusions and weigh the multiple factors contributing to the patient presentation [15, 16]. The comb reminds learners that it will take multiple visits over time to sort out these factors into definable diagnoses and syndromes. Becky's Braids represent management reasoning. Plans must be as comprehensive as possible, addressing both underlying processes and what matters most to our patients, but not so overwhelming or arduous as to prohibit adoption. Recognition of multiple contributing factors enables the treating clinician to see multiple avenues of intervention for a given problem. Effective plans weave together feasible strategies, anticipatory guidance and supportive counseling, and acknowledge subsequent visits will likely involve some unraveling and creation of new braids. Developing manageable care plans demands awareness of medical and social system constraints, treatment burdens, and patient priorities. The framework offers a structure to guide reasoning as clinicians navigate the multitude of factors in caring for complex older adults. This framework can be used to teach by presenting learners with a case that initially appears to have a clear diagnostic etiology. Additional inquiry can consider other disease processes, look for additional contributing factors, optimize existing treatments, and evaluate the validity of past diagnoses. Considering these layers of complexity can help set the expectation that changes will be made one step at a time. The iterative nature of the process can be emphasized, with response to each intervention prompting re-evaluation of initial conclusions and plans. Table 1 outlines examples of this process with two clinical cases. 83-year-old woman presents with urinary urgency that has led to episodes of incontinence. Medical history: Hypertension, osteoarthritis, mild cognitive impairment Medications: Amlodipine, hydrochlorothiazide, donepezil Exam: Notable for peripheral edema, antalgic gait Occam's Razor: urge incontinence Hickam's Dictum: adds arthritis as a barrier to reaching the bathroom in time. Kevin's Comb: adds further considerations, including Hydrochlorothiazide may have been added for amlodipine-induced edema Diuretic and cholinergic side effects may be contributing to urinary frequency Evaluation for potential hazards within the home contributing to fall risk when rushing to the bathroom Becky's Braids: construct a patient-centered care plan Medication adjustment Scheduled toileting Physical therapy Home safety evaluation Close follow-up to evaluate effectiveness/acceptability of care plan, re-assess symptoms and adjust plan accordingly 67-year-old man with mild cognitive impairment and hallucinations presents with a new tremor and multiple falls after starting risperidone. Medical history: Depression, insomnia, diabetes mellitus type 2, pancreatic insufficiency, obstructive sleep apnea managed with CPAP Medications: Sertraline, zolpidem, risperidone, pancrelipase, insulin glargine Exam: notable for recent weight gain, pill-rolling tremor, slow shuffling gait, decreased light touch sensation to knees, in fingers Occam's Razor: Lewy body dementia Hickam's Dictum: identifies zolpidem contributing to fall risk and cognitive changes Kevin's Comb: adds further considerations, including Depression assessment, as that may be contributing to cognitive changes Diabetes assessment as over- or under-treatment may contribute to falls and cognitive changes Evaluation for diabetic neuropathy contributing to falls Medical history timeline, revealing pancreatic insufficiency diagnosis was preceded by addition of metformin and sertraline, with improvement of diarrhea after stopping metformin and adding pancrelipase Becky's Braids: creates the expectation of a step-wise management plan including: Attempt de-prescribing risperidone. If hallucinations persist, consider quetiapine as an alternative with fewer EPS side effects Collaborative zolpidem taper focusing on sleep quality Re-evaluating pancreatic insufficiency diagnosis, potential ongoing diarrhea side effect from sertraline Evaluation of ability to manage insulin Diabetic foot care PT evaluation for assistive device, balance training Close follow-up to evaluate effectiveness/acceptability of care plan, re-assess symptoms and adjust plan accordingly The authors have used this framework in community talks, grand rounds, student teaching, and faculty workshops. At the bedside, sketching a web of complaints and contributing factors reassures learners that their sense of overwhelm reflects the complexity of the situation, not a failure on their part. It can also be a helpful visual to set expectations for patients, understanding the expectation for re-evaluation and management plan adjustment with repeated passes of the comb, unraveling and refreshing the braids. Part of the joy of geriatric medicine lies in integrating diverse contributors to patient complaints and constructing care plans that address both disease processes and lived experience. However, this complexity can overwhelm clinicians, learners, and patients alike. Conceptual frameworks that both acknowledge complexity and guide practical care are essential. Kevin's Comb and Becky's Braids provide a visual, iterative, and patient-centered approach to diagnostic and management reasoning in geriatric medicine. The conceptual model was developed and the manuscript authored by both R.J.S. and K.C. The authors would like to thank Joshua DeGraff (Manager of Library Technology, Schaffer Library of Health Sciences, Albany Medical College) for creating a polished visual version of Kevin's Comb and Becky's Braids. The authors would also like to thank Meryl Gold, MD (Department of General Surgery, Metabolic and Perioperative Support, Albany Medical College), Rachel Hathaway, MD (Department of Internal Medicine, Albany Medical College), and Wayne Sheldon, PhD (Alden March Bioethics Institute, Albany Medical College) for their review and suggestions. The authors have nothing to report. This manuscript was initiated by the authors. There was no sponsor. The authors declare no conflicts of interest.