teaching clinical reasoning - geisel school of...
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Teaching Clinical Reasoning
On Doctoring Faculty Development
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Objectives • Work through a Clinical Problem Solving case • Overview of Learning theory and vocabulary
• Strategies for practice with learners • Outline for Year 1 and Year 2 On Doctoring
Clinical Reasoning sessions
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Lecture: Retention < 10% Active Learning Better Results
50%
Reading
Lecture
Audiovisual
Demonstration
Discussion
Practice Doing
Teach Others
30% 20% 10%
75%
90%
Source: National Training Laboratories, Bethel, Maine
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How do doctors think? The exhaustive method, encouraged for use by medical
students and residents § Gather every bit of data possible, don’t miss a thing!
Then try to come up with a diagnosis.
Hypothesis generation, preferred by seasoned clinicians, incorporating Bayesian reasoning § Propose an explanatory hypothesis- see if it “fits” the
story. Revise as you go along.
Pattern recognition, employed by experienced clinicians § You’ll know it when you see it- you’ve seen it before
The reality-a combination of these methods
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Metacognition
Awareness or analysis of one's own learning or thinking processes
Understanding the cognitive processes involved in clinical reasoning is helpful in
building reasoning skills
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Case
27 yo unemployed man admitted to the ED with shaking chills and fever x 4 days accompanied by sweats. He had some shortness of breath on exertion and a mild HA x 3 days. Appetite is poor, but no other GI sx. Able to keep hydrated and make urine.
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Case
The patient said that he had been bitten by a friend’s cat a week prior. ROS is positive for a h/o transient vision loss right eye which lasted 45 seconds one day prior.
SH: Lives with his parents. Not in a relationship
Habits: Smoker 10 pack years. Drinks 4-5 beers/week
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Case
PE: Toxic looking young man, rigor T: 103, P 124, BP 110/40 Puncture wounds rt forearm, no
cellulitis or abscess HEENT: Flame shaped hemorrhage left
fundus 2/6 early diastolic murmur in the
aortic area. Lungs clear. No spleen.
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3 min Case Discussion
• Partner up and discuss the case. What do you think is going on?
Pay attention to HOW you think about the case?
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Diagnos)c Reasoning
Patient with a complaint or problem
DDx for this problem
DDx for this patient
Working DDx
Final Dx
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Diagnostic Reasoning
• When we teach: – We take a history – Then do the physical exam – And then and only then have students
figure out how things fit together
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Diagnostic Reasoning (Iterative Process)
• In prac)ce, the pa)ent’s age and chief complaint get clinicians thinking immediately – thinking about the general DDx for the CC in that pa)ent – this guides their ques)ons – answers lead to revision of the working DDX – This prompts more ques)ons (in a search for defining and discrimina)ng features) and further refines the DDX
• This is “co-‐selec)on” – an itera)ve process of simultaneous data-‐gathering and searching for “illness scripts”.
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Diagnostic Reasoning (an unconscious itera)ve process)
Pa)ent’s story
Data acquisi)on
Summary statement
Hypothesis genera)on
Search for illness script
Diagnosis From Bowen 2006
Reasoning process
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Iterative Reasoning Process
Gather data
Refine Summary Statement
Refine Hypotheses
Search for illness script
match
Chief Complaint
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Case Dissection
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Key Steps
• Organizing/activating knowledge
• Accurate summary statement: helps sort through mental “illness data match” (illness scripts)
• Awareness of heuristics and medical errors
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Think out aloud
• Activate the student’s prior knowledge
• Help them make connections
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Case: Key Findings History
• Young male • Unemployed • Febrile, sweating , ill • Cat bite • Transient vision loss
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Activating Prior Knowledge: History
• 27 yo male ? Risk factor • Unemployed ?Substance abuse • Febrile, sweating, ill Infection • Cat bite Infection • Transient vision loss Neuro/Vasc Hypotheses vs Objective data
Osteo, Endo, HIV, Hepatitis
P.Mult Strep S.Aur Cat
scratch
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Case: Key findings PE
• BP 110/40
• Flame shaped hemorrhage
• 2/6 early diastolic murmur in the aortic area
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Activating Prior Knowledge: PE
• What does a high pulse pressure mean? What causes this?
• What are the causes of flame shaped hemorrhages?
• What are the causes of diastolic murmurs?
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Stimulate Self Questioning
• Explain why… • Explain how… • What is the main
idea of…? • What is another
example of…? • What would
happen if…?
• What is the diff. between…and…?
• How does…affect…? • What are the
strengths and weaknesses of…?
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Key Steps
• Organizing/activating knowledge
• Accurate summary statement (leads to accurate choice of illness script)
• Awareness of heuristics and medical errors
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Case :Summary Statement
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Case: Summary statement
• 27 year old with a h/o cat bite who comes in with fever, rigors, transient vision loss and found to have hypotension, flame shaped hemorrhage and a new diastolic murmur.
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Summary Statement
• An accurate Summary Statement triggers and guides the hypothesis generation (next step in framework).
• Requires deliberate practice
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Diagnostic Reasoning
Pa)ent’s story
Data acquisi)on
Summary Statement
Hypothesis genera)on
Search for illness script
Diagnosis From Bowen 2006
Reasoning Process
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Illness Scripts: A way to Organize
• Instead of storing clinical information discretely, experienced clinicians store and recall knowledge as diseases, conditions or syndromes – also called “illness scripts” (Bowen 2006)
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Illness Scripts
General format: • Risk factors/epidemiology • Pathophysiology • Clinical features
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Illness Script
• Mental representation of a diagnosis/disease entity.
– Built by starting with textbook or classic case
– then refined based on experience and further learning.
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PATHOPHYSIOLOGY
Infec)on of the lung parenchyma
airway inflamma)on
EPIDEMIOLOGY The very young or old Immunosuppressed
Smoking
CLINICAL FEATURES Fever, Cough, Pleuri)c chest
Pain, Tachypnea
Illness Script: Pneumonia
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Illness Script for gout • Epidemiology: age > 40, male,
alcohol use, diuretics • Pathophysiology: altered uric acid
metabolism, joint crystal deposition, inflammation
• Clinical features: acute pain, monoarticular – first MT, recurrent
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Illness Script • Mental memory of a clinical condition
or set of features of an illness– – Build blocks of information for each disease – As you build these blocks of information, they form
crosslinks/ references – so that as soon as you think about an illness – you automatically begin to think about another related one.
• How information is stored helps determine how
effectively it is retrieved • Experience helps “fill the cabinet”, organize,
reorganize, cross-link & refine the scripts for each illness
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Semantic Qualifiers
• Febrile Afebrile • Acute Chronic • Young Old • Recurrent Single episode • Surgical Non-surgical
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Sep)c Arthri)s
JRA Gout
Defining, Discrimina)ng Features
Discrimina)ng Features Defining
Features
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Cat bite celluli)s
Cat bite endocardi)s Cat scratch
Defining, Discrimina)ng Features
Discrimina)ng Features Defining
Features
From Bowen 2006
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Practice summary statement using semantic qualifiers
• 65 yo man with severe left knee pain. This has happened a couple of times before although in other joints. Often it occurs after he’s had several glasses of red wine.
• Older gentleman with recurrent monoarticular arthritis often associated with alcohol use.
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Heuristics (Rules of thumb)
• Heuristics are useful but can often lead to systematic errors
• The accurate intuition of experts can be explained by the effects of prolonged practice rather than reliance of heuristics alone
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Examples of Cognitive Errors
• Anchoring/Premature closure
• Availability/Last case bias
• Attribution/ Sterotype Croskerry 2003 The Importance of Cognitive Errors in Diagnosis and Strategies to
Minimize Them Bordage 1999, Why did I miss the diagnosis? Some cognitive explanations and
educational implications
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Bias Prevention: 3 Questions
• Ask: What else can it be?
• Does anything NOT fit in this story?
• Could 2 things be going on?
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Strategies for Practice with Students
Presentations—what can go right or wrong?
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Presentations
• Why so much attention to presentations?
• Presentations = window into thinking
• Process of presenting helps
solidify reasoning skills • Presentations take an
abstract process and make it explicit
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Strategies • Useful for diagnosing the problem as well as
reframing for practice.
• Overlap…not cut and dry which are best for what
problem
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Strategies • Compare/Contrast DDx
– Horizontal Reading
• Iden)fy Defining/Discrimina)ng Features – Highlighter Exercise – Reverse Presenta)on
• Concise Summary Statements – Summary Statement Lis)ng Seman)c Qualifiers
• Prac)cing your DDx – Reasoning through the Assessment – DDx shortcuts—Acronyms, Strategies
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“Read About Your Patients”: Vertically (This gives you knowledge)
Patient 1: ITP • Epidemiology
• Pathophysiology • Clinical features
• DDx – HSP
– Leukemia – Meningococcemia…
• Treatment • Complications
Patient 2: ABO Incompatibility
• Epidemiology • Pathophysiology • Clinical features
• DDx – Breast feeding
jaundice – G6PD deficiency
– Prematurity – E. coli sepsis… • Treatment
• Complications
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Horizontal Reading • Read about similar/overlapping diagnoses at the same time.
• Lays down the cross-referencing as you file the scripts.
PURPURA HSP ITP Leukemia
Time course O^en a^er viral illness
O^en a^er viral illness
Exam features
Afebrile, no HSM
Afebrile, no HSM
May have fever, HSM
Lab features Normal platelets
Low platelets Normal or Low
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Strategies • Compare/Contrast DDx
– Horizontal Reading
• Iden)fy Defining/Discrimina)ng Features – Highlighter Exercise – Reverse Presenta)on
• Concise Summary Statements – Summary Statement Lis)ng Seman)c Qualifiers
• Prac)cing your DDx – Reasoning through the Assessment – DDx shortcuts—Acronyms, Strategies
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Case of “data dump” • 16 yo male presents w/abdominal pain x 24 hrs
• Pain began yesterday in the RLQ. – Started at 10AM. Got better at 10:30, but worse again
by 11AM. – Gradually worsened and got better just before bedtime
but then worse again after waking up this morning.
• Decreased PO intake – Had a normal breakfast—toast with butter, glass of
orange juice. Though some days he skips breakfast. – Lunch was decreased. Bought a bagel with cream
cheese but only ate half. Saved the other half for dinner
– Dinner—he forgot about the bagel, but instead had spaghetti which his mother made for him.
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Presentations: Faulty Clinical Reasoning:“Symptoms”
• Problems with presentation of data – Unfiltered data
dump – Disorganized – Missing important
information
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Underlying Problem?
• Insufficient knowledge • Organization of knowledge • Recognition of defining, discriminating
features
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Iden)fying Defining and Discrimina)ng Features • Highlighter—literally practice
highlighting • Take MS note, yellow pen…
– Practice highlighting defining and discriminating features
• For the purpose of make a diagnosis • For purpose of highlighting pertinent
findings for deciding on a treatment plan – Can highlight in another color details
that are redundant or not pertinent
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Identifying Discriminating Features: Reverse Presentation
• S • O • A • P
• A • S • O • A • P
This is a way to prime a preceptor to give feedback on the order, organization, selection of details presented
“Joey is a 19yo with CC of fever and cough who likely has
Pneumonia. Here’s why:” then presents S-O-A-P
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Strategies • Compare/Contrast DDx
– Horizontal Reading
• Iden)fy Defining/Discrimina)ng Features – Highlighter Exercise – Reverse Presenta)on
• Accurate and Concise Summary Statements – Summary Statement Lis)ng Seman)c Qualifiers
• Prac)cing your DDx – Reasoning through the Assessment – DDx shortcuts—Acronyms, Strategies
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¡ You have had a headache on and off for the past month. You are afraid you have a brain tumor
¡ The doctor you are seeing has never met you and seems to be in a rush.
¡ You have 20 seconds to persuade me that you need a head CT to rule out a mass.
¡ What will you say?
Identifying Discriminating Features: Persuade Me
forces identification of essential features
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Strategies
1. Metacognitive overview 2. Horizontal reading 3. Coaching to promote co-selection 4. Highlighter Exercise 5. Persuade the MD 6. Reverse Presentation 7. Problem Representation 8. Assessment 9. Disease Likelihoods 10. Differential Diagnosis
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Coaching to promote Iterative thinking
Gather data
Refine Summary Statement
Refine Hypotheses
Search for an illness script
Chief Complaint
Prime: • Ini)al DDx?
• What informa)on?
Learners can be coached to do this deliberately
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Presentations: Symptoms of Faulty Clinical Reasoning
• Inaccurate assessment – This is a movie star dressed up as
a dog for Halloween. • Missing assessment
– SOP: • This is a hairy animal with
fluffy tail, in a top hat and tuxedo, my plan is to give it a cane.
– SOSOP • This is a hairy animal with
fluffy tail, in a top hat and tuxedo. So, for assessment, this is a hairy animal with fluffy tail, in a top hat and tuxedo. Plan is to give it cane.
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? Underlying problem
• Inadequate summarization
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Summary Statement Listing Semantic Qualifiers
• Write a 1-2 sentence summary of Joey’s key findings, using semantic qualifiers
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Summary Statement listing semantic qualifiers
Deliberate practice with summarizing, using semantic qualifiers & highlighting key features.
This is a • Young adult male with • acute onset of • productive cough, • high fever, • tachypnea, and a • pleuritic chest pain
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Strategies • Compare/Contrast DDx
– Horizontal Reading
• Iden)fy Defining/Discrimina)ng Features – Highlighter Exercise – Reverse Presenta)on
• Accurate and Concise Summary Statements – Summary Statement Lis)ng Seman)c Qualifiers
• Prac)cing your DDx – Reasoning through the Assessment – DDx shortcuts—Acronyms, Strategies
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Problems with the DDx • Disembodied DDx:
– A generic differential for the initial complaint rather than a differential specific to the patient
• Silo DDx: – A separate DDx for each symptom or key finding, rather than
a differential for the constellation of findings taken together • Frozen DDx:
– Continues to include items on the DDx that have been ruled out by new information – or continues to present a multi-item differential after a final diagnosis has been confirmed
• Unprioritized/inappropriately prioritized DDx: – Assigns inappropriate weight/probability to items on the DDx
• Zebra DDx: – DDx includes one or more rare, esoteric, highly unlikely
diagnoses
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Problems with DDX
• Disembodied DDx – This is an animal, so ddx includes cat, cow… – Incomplete illness script
• Silo DDx – Creates the ddx for the dog’s ear, nose, or tail
• Frozen DDx – Even though you recognize it runs and barks,
unable to adjust ddx – Failure to seek a new script
• Zebras and unicorns – We can’t discount this may be a were-wolf
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Components of a Well-Reasoned Assessment
• Summary Statement • Differential with commitment to
the most likely diagnosis • Explanation of reasoning in
choosing the most likely diagnosis • Alternative diagnoses and
explanation for why they are less likely
Baker, 2010
Student thinks out loud about summary statement and differential diagnosis
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Dog
Horse Cat
Clinical findings:
• Runs • Barks
• Furry Tail • Tongue sticking out
“Disease” Likelihoods
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“Disease” Likelihoods
Runs Barks Furry Tail Total
Dog ++ +++ ++ 7 Horse +++ - ++ 4 Cat + - ++ 2 Tree - ++ - 0
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Disease Likelihoods
Fever Tachypnea Cough Total
Pneumonia ++ +++ +++ 8 URI + + ++ 4 Foreign Body
- + +++ 3
UTI +++ - - 1
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Traditional – use to expand DDx
• V Vascular • I Infectious,
Inflammatory
• N Neoplastic • D Degenerative • I Iatrogenic,
Idiopathic • C Congenital • A Autoimmune,
Allergic • T Toxin, Trauma • E Endocrine
Metabolic
Differential Diagnosis Strategies
Alternative –use to prioritize
DDx
• Common • Atypical presentation
• Rare diagnosis
• Severe
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Cases
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For each case
• What are the symptoms of faulty reasoning?
• What might be the underlying problems?
• What coaching strategies might be helpful?
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Cases: Guidelines
• Assume that data presented in each case represent exactly what the student has gathered
• Algorithm • Problems and strategies overlap • Include ideas from your own
experience
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Parting Ideas
• Start with a metacognitive frame – Let the learner know you’ll be
teaching them about thinking • Target specific steps in the
reasoning process for deliberate practice
• Experiment with different strategies to find a good fit
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Discussion of course strategy for Year 1 and Year 2 On Doctoring
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Year 1
• Introduce concept of clinical reasoning in broad terms from early case discussions and write ups.
• Session on formal intro to CR winter/spring term using a simple case
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Year 2
• Sept 20:Introduction to CR with a Pneumonia case (small group)
• Oct 18: Chronic illness: Diabetic with cellulitis case (small group)
• Nov 1: Pericarditis case (small group)
• 2 additional sessions winter/spring: Pediatrics and surgical cases
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References
Stuart E, Blankenburg B, Butani L, Johnstone N, Long M, Marsico N. COMSEP Workshop: Thinking about Thinking: Coaching to Promote Effective Clinical Reasoning