1 Systems Based Practice (SBP) Dempsey Springfield, MD Associate Director for Partners GME.
Clinical Reasoning: Minding the GAP from UME to GME · Construct a Concept Map Let’s practice! On...
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A FACULTY DEVELOPMENT WORKSHOP Clinical Reasoning: Minding the GAP from UME to GME
Transcript of Clinical Reasoning: Minding the GAP from UME to GME · Construct a Concept Map Let’s practice! On...
A FACULTY DEVELOPMENT WORKSHOP
Clinical Reasoning: Minding the GAP
from UME to GME
Faculty
• Roshini Pinto-Powell— Dartmouth
• Shanu Gupta—University of South Florida
• Joel Appel—Wayne State University
Objectives
1. Clinical reasoning cognitive theory
2. Terminology
a. illness script, semantic qualifiers
b. problem representation
3. Cognitive biases
4. Five domains of clinical reasoning difficulties
5. Case examples of clinical reasoning errors
Audience
Survey
A Case
Abdominal x-ray:
- bowel gas paucity in the RLQ
suggestive of intussusception
Transferred for surgical
consultation
12 day infant presents with vomiting and bloody stool
- Onset: 6 days old
- Vomiting, followed by irritability and diarrhea
Switched formula, did not relieve
symptoms.
Six days later:
- bloody stools with mucus
- periods of inconsolable crying
Contrast enema:
- equivocal data
- contrast media failed to progress at the hepatic flexure
- suspicious for intussusception, although atypical
Abdominal examination “benign”
Continued crying spells
Small bowel follow-through:
- malrotation!
Ultrasonography:
- no intussusception
Patient underwent an uncomplicated surgical
correction for the malrotation.
What
happened?
Dual Process Theory of Decision
Making
• System 1 is FAST
• System 2 is SLOW
Clinical Reasoning Process
An Iterative Cycle
Chief Complaint
Bowen: NEJM 2006
Clinical Reasoning Process
Key Steps
• Organizing knowledge and gathered clinical
information
• Data synthesis & problem representation development
• Illness script scanning & differential diagnosis formation
• Awareness of cognitive biases
Clinical Reasoning Process
Organizing Knowledge
What are the key features from the history and PE?
e.g.,
• Tempo/course of the CC/HPI
• Age, exposures, other risk factors
• General appearance on exam and key findings
Recognize pertinent positive AND negative findings
Organizing & Interpreting Clinical Information
Case example
History:
12 day old with vomiting and bloody stool.
Symptoms began on day 6 with irritability and diarrhea.
Change of formula did not help.
Day 12 presents with diarrhea (blood and mucus) and
inconsolable crying (?pain)
Organizing & Interpreting Clinical Information
Key & Differentiating Features
Intussusception
Milk protein allergy Volvulus/
Malrotation
Key Feature(unique to that disease:
abdominal mass)
Differentiating
Feature(unique to a subset of diseases:
Possible genetic
predisposition, medical
emergency)
DifferentialConstellation of signs
and symptoms that are
common to several
diseases: vomiting,
bloody diarrhea,
colicky pain) Bowen, 2006Organizing Knowledge and Information,
Dr. Catherine Lucey
Clinical Reasoning Process
Key Steps
• Organizing knowledge and gathered clinical information
• Data synthesis & problem representation
development
• Illness script scanning & differential diagnosis formation
• Awareness of cognitive biases
Patient demographics (age, gender)
+ chief complaint
Patient demographics
+ key findings in the history
Patient demographics
+ key findings in the history +
physical examination/data with SQs
12 day old infant with vomiting and
bloody diarrhea
12 day old infant doing well until day 6,
presents with diarrhea and irritability
progressing to vomiting and bloody
diarrhea
12 day old infant with acute vomiting,
bloody diarrhea and a benign
abdominal exam with x-ray and US
findings atypical for intussusception
Data Synthesis
Problem Representation: Case
Case example
Summary Statement
12 day old infant with acute onset of vomiting, bloody
diarrhea, intermittent inconsolable crying and a benign
abdominal exam. X-ray and US findings are atypical for
intussusception.
Clinical Reasoning Process
Key Steps
• Organizing knowledge and gathered clinical information
• Data synthesis & problem representation development
• Illness script scanning & differential diagnosis
formation
• Awareness of cognitive biases
Illness Scripts
▶ Epidemiology
▶ Who gets the disease? Demographics,
risk factors
▶ Temporal course
▶ Duration, pattern
▶ Pathophysiology
▶ Biomedical causes? Genetics,
immunology, physiology, microbiology
▶ Clinical presentation
▶ Key features
Illness Scripts
Illness Script for Intestinal Malrotation
Epidemiology: Congenital anomaly of the rotation of the
midgut, occurs between 1:200 to 1:500 live births. Most
asymptomatic. 1:6000 symptomatic
Time course: sudden onset, progressive symptoms once
symptomatic
Pathophysiology: Disruption of the normal embryologic
development of the bowel. Many variations.
Clinical Presentation: sudden onset of bilious emesis with
diffuse abdominal pain out of proportion to exam. Ischemic
bowel leads to bloody diarrhea.
Diagnosis A?
(best match; most likely malrotation)
Diagnosis B?
(poor match; unlikely intussusception)
Diagnosis C?
Illness Script Scanning & DDx Formation
Prioritizing the Differential
Diagnosis
(less likely; milk protein allergy)
Hypothesis-driven data gathering
Working
diagnosis
- most likely
- change at any point
Data interpretationHypothesis testing
Hypothesis revision
Illness Script Scanning & DDx Formation
The Working Diagnosis
Clinical Reasoning Process
Key Steps
• Organizing knowledge and interpreting clinical information
• Data synthesis & problem representation development
• Illness script scanning & differential diagnosis formation
• Awareness of cognitive biases
3 Common Cognitive Errors
Anchoring bias• Latch onto first symptom or finding, failing to adjust
▶ Pulmonary embolism can cause chest pain and shortness of breath, so it must be a PE. Ignore the fever of 102.
Availability bias• A recent case
▶ Just saw a case of PTX present just like this, so this patient likely has a PTX.
Ascertainment /Stereotype bias• Stereotype
▶ Smokers get lung cancer, so that’s probably the cause of this patient’s bloody sputum.
Croskerry, Acad. Med 2003
Let’s Practice!
On your table, pick a case from Practice Cases A:
- develop a problem representation
- identify illness scripts sparked by the problem
representation
- compare and contrast the illness scripts to
prioritize your diagnosis
Illness Scripts
▶ Epidemiology
▶ Who gets the disease? Demographics,
risk factors
▶ Temporal course
▶ Duration, pattern
▶ Pathophysiology
▶ Biomedical causes? Genetics,
immunology, physiology, microbiology
▶ Clinical presentation
▶ Key features
Debrief
● Problem representation
● Illness scripts
● Comparing Illness scripts
● What did you and/or your group say or do
that was effective?
BREAK
Concept Maps
Looking at the big picture
Daley B, Durning S, Torre D
MedEdPublish
https://doi.org/10.15694/mep.2016.000019
Water
Living
Things
Molecules
States
changes
made of
needed by
TOPIC
NODE
MODIFIER;
VERB
BRANCHING
NODE
Plants
Animals
is a type of
is a type of
Solid
Liquid
Gas
FEVER/CHILLS COUGHINFECTION
PGs increase body
temp set pt via
hypothalamus
Acute inflam
cytokines
Innate and adaptive
immune response
Production of ABs,
immune cells, inflam
mediators
VasodilationIncreased vasc
permeability
TACHYCARDIA
HYPOTENSION
Cough reflex via
vagus to medulla
Mucus production
and secreted ABs;
destruction of
microbe
Mucus and pus in
alveoli
Hypoxemia
Chemorec stim
TACHYPNEA
Blocked airways
forced open with
deep insp
CRACKLES
DULLNESS TO
PERCUSSION
Enhanced sound
transmission thru’
fluid vs air
EGOPHANY
Construct a Concept Map
Let’s practice!
On your table, pick a diagnosis from the
differentials you developed in Practice Cases
A:
- construct a concept map for that
diagnosis
Debrief
● Problem representation
● Illness scripts
● Comparing Illness scripts
● Concept maps
● Where/how do they fit in with teaching
clinical reasoning?
BREAK
Diagnose RemediateDiagnoseTeach
Failure to identify chief concern.
Poorly synthesized OP.
Documentation lacks synthesis.
Difficulty Prioritizing
Patient specificities not explored.
OP lacks biopsychosocial complexity.
Unclear interpretive summary.
Synthesizing / “Seeing Big Picture”
Rigid interview and PE disconnected to the patient complaint.
Disorganized OP and written documentation.
Assessment lacks semantic qualifiers. DDx too limited and not justified.
Difficulty Generating Hypotheses
Confirms hypothesis during data gathering.
Alternative hypotheses missing from OP and written documentation.
No DDx is provided.
Premature Closure Inappropriate plan, not adjusted as the case evolves.
Lacks patient perspective or psychosocial aspects.
Lack of consistency between the DDx and the management plan.
Difficulty : Management/Plan
GAP in Clinical Reasoning
•Gathering Data•Difficulty gathering data (hx taking, PE skills)
•Difficulty generating hypotheses (knowledge)
•Appraising Data•Difficulty seeing overall picture
•Difficulty prioritizing
•Difficulty coming up with a management plan
•Probing for Bias and other causes•Premature Closure/Availability/Confirmation Bias
•Learning environment
Failure to identify chief concern.
Poorly synthesized OP.
Documentation lacks synthesis.
Difficulty Prioritizing
Patient specificities not explored.
OP lacks biopsychosocial complexity.
Unclear interpretive summary.
Synthesizing / “Seeing Big Picture”
Rigid interview and PE disconnected to the patient complaint.
Disorganized OP and written documentation.
Assessment lacks semantic qualifiers. DDx too limited and not justified.
Difficulty Generating Hypotheses
Confirms hypothesis during data gathering.
Alternative hypotheses missing from OP and written documentation.
No DDx is provided.
Premature Closure Inappropriate plan, not adjusted as the case evolves.
Lacks patient perspective or psychosocial aspects.
Lack of consistency between the DDx and the management plan.
Difficulty : Management/Plan
Gathering
Appraising
Appraising Appraising
Probing
Gathering Data Difficulty gathering data (hx taking, PE skills)
Difficulty generating hypotheses
(knowledge)
Tools for Differential Formation
• Organ System Based Ddx
• Abdominal Pain: GI vs GU vs GYN causes
• Pathophysiology Based Ddx
• AKI: “Pre-Renal” vs Intrinsic Renal Disease vs “Post-
Renal” AKI
• Thrombocytopenia: Production vs Destruction vs
Sequestration
• VINDICATED for expansion of Ddx (Vascular;
Infectious; Neoplastic; etc.)
AppraisingDifficulty Prioritizing
• Justify the Differential Diagnosis
• Assessment with Summary Statement
• Differential diagnosis
▶ commitment to most likely
• Reasoning for most likely diagnosis
• Reasoning for alternatives as less likely
Justifying the Differential
Diagnosis in our case
• Baby Joey a 12 day old infant, well until day 6, who presents day 7 after birth with vomiting, bloody diarrhea and crying spells. W/u revealed a negative abdominal US and a SBFT showed intestinal malrotation.
• Ddx of bloody diarrhea in this infant included milk protein allergy and intussusception
• Malrotation is however most likely given the positive SBFT. The negative US made intussusception less likely and the persistence of the bloody diarrhea despite formula change made that diagnosis less likely as well.
Appraising
Difficulty Prioritizing
• Compare common and “can’t miss” etiologies
e.g. Headache - prioritize by LRs
Common Can’t Miss
Migraine Headache Brain Tumor
Tension Headache Meningitis/Encephalitis
Sinus Headache Vasculitis
Cluster Headache Intracranial Hemorrhage
AppraisingDifficulty Seeing the Big Picture
• Summary Statement using Semantic Qualifiers
• List out the key findings using semantic
qualifiers
• Using that list, create a 1-2 sentence
summary statement with those key findings
• Joey is a 12 day old
• Male infant
• Acute onset bloody diarrhea on day 7
• Non projectile vomiting
• Benign abdominal exam
AppraisingDifficulty Seeing the Big Picture
• A-SOAP instead of SOAP
• Primes the learner to organize and select details that
support the big picture and working diagnosis /
assessment
• Baby Joey a 12 day old infant, well until day 6, who
presents day 7 after birth with vomiting, bloody diarrhea
and crying spells, who likely has intestinal malrotation.
• He was in his usual state of health until day 7 when
he…..
• …and so on… (S-O-A-P presentation)
AppraisingDifficulty with Management Plan
• Highlighting
• Key features and discriminating features
• Pertinent findings
▶ treatment plan/evaluation
▶disposition (home vs admit; inpatient
unit vs intensive care unit)
Probing for Bias
• Comparison
table
• Highlighting• Key/ Discriminating Features
• Pertinent findings
*Use for hypothesis generation: pertinent vs unnecessary information
Probing for Bias
•Prevention Questions
•What else could this be?
•Does anything NOT fit in this story?
•Could more than 1 thing be happening in this
patient?
Practice Cases using Student
write-ups
Work on cases either in pairs, trios, or as a full
table
• Diagnose the clinical reasoning difficulty(ies) for each
case
• Come up with a remediation/teaching strategy for the
learn
• Use the Table/Handout to record your discussion
• Choose a Scribe to fill out the Handout
• Choose a Reporter to share your discussion
during large group debrief
Cases and Handouts
▶ Cases: ▶ Remediation tools:
Large Group Work Debrief
• For each case in your packet
• How would you diagnose the learners gap in
Clinical Reasoning?
• How might you remediate them?
• Report out in large group
• What Domains of Difficulty did you discuss?
• What Remediation Strategies did you come
up with?
• Were there challenges using just these 5
domains?
Our Thoughts...Ou
Mind the GAP - DIAGNOSE
Gathering data
Appraising the data appropriately
Probing for bias and other causes
Mind the GAP - REMEDIATE
Gathering data:
- knowledge
- interrogatory
- physical exam skills
Probing for bias and
other causes:
- metacognition
- learning
environment
Appraising the data
appropriately
- organ
systems/pathophys
- A-SOAP
- summary with
semantic qualifiers
- highlighting
- DDx tables
- concept maps
Take Home Points
1. Problem representation is a pivotal step
to clinical reasoning
2. Framework to diagnose your learner -
Audetat’s five domains of clinical
reasoning difficulties
3. Mind the GAP!
Diagnose Remediate Action Plan
G Gathering Data Knowledge
Interview and Communication skills
Physical exam skills
Give Targeted Feedback
A Appraising Data Organ systems/pathophys
A-SOAP
Summary with semantic qualifiers
Highlighting
DDx tables
Concept maps
Address Learner Concerns
P Probing for Bias and
Other Causes
Metacognition
Learning Environment
Plan to Follow-up
And Follow-up
Gupta S, Appel J, Pinto-Powell R - 2019
Weinstein A, Gupta S, Pinto-Powell R, et al. Diagnosing
and remediating clinical reasoning difficulties: a faculty
development workshop. MedEdPORTAL. 2017;13:10650.
https://doi.org/10.15766/mep_2374-8265.10650
