170 - tips for teaching clinical reasoning syllabus/170 - ti… · dr. fred janke • sylvan lake...
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Society of Rural Physicians of Canada 26TH ANNUAL RURAL AND REMOTE MEDICINE COURSE
ST. JOHN'S NEWFOUNDLAND AND LABRADOR APRIL 12 - 14, 2018
• 170
Dr. Fred Janke • SYLVAN LAKE • AB
TIPS FOR TEACHING CLINICAL REASONING Clinician teachers often struggle with teaching clinical reasoning. Three different methods for teaching clinical reasoning will be explored with a focus on effective questioning. Preceptors frequently use questions as a method of teaching in the clinical setting. However, the nature of questioning can have a significant impact on what is taught in the clinical context. By developing skill in questioning, clinician educators can become more effective at teaching clinical reasoning and decision making. In this workshop, participants will use case examples, guided exercises and group discussion, to analyze and develop their questioning skills to enhance the teaching of clinical reasoning and clinical decision making. 1. At the conclusion of this workshop, participants will be able to list three different techniques in teaching clinical reasoning. 2.) At the conclusion of this workshop, participants will have better tools in useing questioning effectively to guide learners in the development of clinical reasoning skills.
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TIPS FOR TEACHING CLINICAL REASONINGFRED JANKE
RURAL AND REMOTEAPRIL 2018
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• Full time faculty of the University of Alberta, thus am paid by the U of A
• No association with any third party who provides financial rewards• No industry or pharmaceutical association
• Have never been paid for a presentation
• Will not promote any Rx or Device in this workshop
CONFLICT OF INTEREST DISCLOSURE
• I snore
• I am obese (but trying not to be)
• I love jazz and often use music in my presentations
• I can have very selective hearing and memory
OTHER DISCLOSURES
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• At the conclusion of this workshop participants will be able to list three different techniques in teaching clinical reasoning
• At the conclusion of this workshop participants will have better tools to use questioning more effectively in the development of clinical reasoning skills
Objectives
• What is clinical reasoning?
• What is your experience with teaching clinical reasoning?
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https://www.youtube.com/watch?v=KlVzMcMv28g
Video
Bowen, N Engl J Med 355;21 www.nejm.org november 23, 2006
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• Dual Processing model of clinical reasoning:• Rapid intuitive component (Type 1)
• Based on illness scripts and heuristics• Slower, logical and analytical component (Type 2)
• When a heuristic is not easily applied
• Diagnostic errors• Failure of a heuristic is referred to as cognitive bias
• Recent literature review, suggests that both thinking processes contribute to errors
• The suggestion that errors occur because of cognitive biases in Type 1 thinking is simplistic
• The most consistent evidence around diagnostic error is deficient clinical knowledge
Duel Processing Model:
Norman et al, Acad Med 2017;92:23‐30
Bowen, N Engl J Med 355;21 www.nejm.org november 23, 2006
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• Allow the learner to watch you problem solve and then unpack your thinking with the learner
• Critical thinking arrow (or Bayesian thinking)
• Socratic questioning to develop clinical reasoning
Tools for teaching clinical reasoning:
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Unpacking your thinking
Unpacking your thinking
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Unpacking your thinking
• Heuristics or illness scripts are unconscious pathways that clinicians use to travel a diagnostic path, based on real patient experience
• Learners have not developed these because o their lack of patient experience
• Unpacking these by working through the discriminators within a clinical problem helps the learner develop his own illness scripts
Unpacking Your Thinking
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Probabilistic Thinking
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Probabilistic Reasoning: Bayesian Thinking
Baye’s Theorem
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A simpler version: The Critical thinking arrow
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22 year old woman presents with headache. What information (or evidence) moves one to the right side for migraine (increased probability)? What information (or evidence) moves one to the right side (increased probability) for tension headache?
Critical thinking arrow
The critical thinking arrow is
Critical thinking arrow
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• Pretest odds for a disease x likelihood ratio = post test odds for a disease
• Pretest probability based on prevalence can often be found in the literature (often as various risk scores)
• Likelihood ratios can be found in other literature such as ACP PIER, Dynamed or JAMA’s Rational Clinical Exam Series
• Searching these out can be a student’s job and can help them understand the rationale
However, you can actually use evidenced based medicine and the math
The process can allow the transformation of a statement such as …
“The negative d‐dimer makes pulmonary embolism unlikely in this patient”
To …
“The negative d‐dimer in our patient with a pre‐test probability of 37.5% based on the Well’s score reduces her post‐test probability to about 5% essentially ruling out pulmonary embolism”
However, you can actually use evidenced based medicine and the math
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Using effective questions
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• To assess knowledge
• To assess understanding
• To assess thought processes
• To engage learners
• To determine a starting point
• To teach all of the above
Why do we question?
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• Before the question, think about the purpose of the question
• Is your question…• Learner centred?
• Knowledge centred?
• Assessment centred?
• Know what you are trying to accomplish with the question
How can questions promote clinical reasoning at different levels of training?
• Questions for clarification of thinking
• Why do you say that? Could you explain further?
• Questions that challenge and probe assumptions
• Is this always the case? What assumptions are you making?
• Questions that probe rationale, reason and evidence
• Is there reason to doubt this evidence?
What can we learn from Socrates? Six types of questions for six different purposes:
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• Questions about about alternative viewpoints and perspectives
• Can you see another way? What is the counter‐argument?
• Questions that probe implications and consequences
• What if…. ?
• Questions about the question
• Why do you think I asked that question?
Six types of questions for six different purposes:
• Divergent versus convergent
• What if?
• Compare and contrast
• For and against
How might we ask deeper questions?
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Junior learners
Mid‐level learners
Senior learners
What makes these different or distinct?
What are you trying to accomplish with each level of learner?
How to probe clinical reasoning with different learners?
• Minimize knowledge questions
• Questions to unpack the problem itself
• Focus on justification:• What speaks for…
• What speaks against …
• Suggest reading around a “presentation” rather than reading around a patient: compare and contrast
Tips and Trick; Junior Learners
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• Provide feedback on interpretive summaries:• What are you ruling out?
• What are the pertinent negatives?
• Prompt to think aloud… explain
• Probe alternative scenarios, highlighting key features
• Justify decisions and expected response to management
Tips and Tricks; Mid‐Level Learners
• Identify a few Socratic questions that you like and keep them in your tool box
• Be explicit about why your are probing
• Be explicit about your own thinking process
• Push learners to consider
Tips and Tricks; Senior Learners
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Break into three groups. We have three students here (junior learners) who each have a case to present. Within your groups discuss and plan your questions to the students as effective Socratic questions.
Exercise
Further questions?
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Fred Janke
Director of Rural and Regional Health
Division of Community Engagement
Faculty of Medicine and Dentistry, University of Alberta