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Teaching Clinical Reasoning In The Apprenticeship Model

THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE. Teaching Clinical Reasoning In The Apprenticeship Model . Nothing. My Thanks. Dennis Baker Greg Turner Lynn Romrell. Goals.

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Teaching Clinical Reasoning In The Apprenticeship Model

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  1. THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Teaching Clinical Reasoning In The Apprenticeship Model

  2. Nothing

  3. My Thanks • Dennis Baker • Greg Turner • Lynn Romrell

  4. Goals • Stimulate discussion of clinical reasoning in the context of curriculum redesign • Share ideas with those who design and implement the 3rd and 4th years of our medical education program.

  5. Objectives • Describe the role of analytical reasoning and pattern recognition in clinical decision making. • Define cognitive bias and give examples of the mental errors resulting from it. • Define framing and give examples of how a physician’s framing of information can lead to an uniformed patient decision • Describe strategies the clinical teacher can use to facilitate the learner’s acquisition of clinical reasoning skills

  6. What opportunities do we have? • Consistent with the U.S. national failure pattern, 10% of our 2nd year students in the past 2 years have failed USMLE step 1. • Additional students have trouble with the first or second NBME shelf exams in the third year. • Many of them struggle with OSCE cases that they represent a “mystery” diagnosis.

  7. Even Among Practicing Physicians • Misdiagnosis is common: 15-20% • Most of the time (80%) these are cognitive errors, not knowledge deficits “Thinking about our thinking as physicians” Jerome Groopman, MD, FACP, and Pamela Hartzband, MD, FACP

  8. What Are We Doing Currently? CurrMIT data: • Clinical reasoning was coded as a topic in 389 session (lectures, labs, small groups, etc.) • We do not know the amount of time spent on the topic or even if it was a major point of emphasis. We just know the topic was covered.

  9. How well are our students doing?

  10. How can we help students develop their clinical reasoning skills?

  11. For the Expert …………… (Benamy, 1996)

  12. For the Learner ……… A Developmental Competency Experience and Deliberate Practice

  13. Deliberate Practice Doing something wrong repeatedly will not improve the outcome.

  14. Clinical Reasoning Definition The process by which clinicians collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the experience. Hoffman, 2007; Kraischsk & Anthony, 2001; Laurie et al., 2001

  15. Clinical Reasoning Concepts • Diagnosis • Hypothesis generation • Context formulation • Test interpretation • Bayesian reasoning • Causal reasoning • Differential diagnosis • Assessing for adequacy • Working diagnosis • Cognitive Errors • Treatment • Treatment under uncertainty • Risk benefit analysis • Treatment thresholds • “Toss ups” • Therapeutic trial • Watchful Waiting

  16. Cognitive Approach To Clinical Reasoning Analytical (Deliberate) • Novice: Does Not Recognize the Pattern • Expert: Case Does not Fit the Pattern Non-Analytical (Pattern Recognition, Intuitive)

  17. Analysis: A Deliberate Approach • Principles of logic and hypothesis testing. Journal Club • Start with what we know. • Problem solving algorithms. Head to Toe, Body Systems, Pathophysiology, Acute vs Chronic, Rule out Worst Case Scenario, Exhaustive method, Deductive (Covered in Doctoring 103) AcadEmerg Med: November 2002, Vol 9, No.11

  18. Curriculum for First Two Years YEAR 1 • Doctoring 1 • Anatomy • Neuroscience • Physiology • Biochemistry and Genetics YEAR 2 • Doctoring 2 • Microbiology • Pharmacology • Pathology • Medicine and Behavior

  19. Constructing a Differential For Syncope • Consciousness requires: • Glucose • Oxygen • Adequate BP and blood flow to deliver above • Organized electrical activity in the brain • Syncope results when any of these are impaired

  20. Probability Bayesian Theory • The predictive value of any diagnostic test is proportional to the prevalence of the disease in the population tested. • Describes uncertainty when potential outcomes are not equally likely. • As evidence is collected the probability is altered.

  21. About 1 out of every 5,000 people in the US has Marfan Syndrome.

  22. Degree of Certainty • Physicians often need to make decisions with incomplete information • We can always do “one more test.” Odds vs. Stakes (Chest Pain, Rectal Bleed) Cost vs. Benefit (Unexplained Wt Loss) Defensive Medicine

  23. Non-Analytical Reasoning

  24. Pattern Recognition Teaching Points • Make the Pattern Fit the Patient, not the Patient Fit the Pattern. (18 month old with lethargy and hyperglycemia) • Don’t stop looking until it fits. • Reconcile symptoms (palpitations, lightheadedness) with findings (EKG, blood glucose)

  25. Avoiding Cognitive Land Mines

  26. Beware! Decisions are not simply a result of logic.

  27. Cognitive Bias • Our attempt to Simplify Complexity • Simple rules of thumb that lead to predictably faulty judgments • Subconscious mental procedures for processing information • Remains compelling even after one is aware of it Center for the Study of Intelligence, CIA, 1999

  28. Examples • Illusory • Omission bias • Outcome bias • Overconfidence bias • Playing the odds • Premature Closure • Representativeness • Restraint • Visceral bias • Zebra retreat • Aggregate bias • Anchoring • Ascertainment bias • Availability • Confirmation bias • Fundamental • Attribution error • Gambler’s fallacy • Gender bias • Hindsight bias Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias by Pat Croskerry, MD, PhD

  29. Overconfidence Bias A willingness to diagnose based on incomplete information when relevant information is available.

  30. Confirmation Bias The tendency to seek out and assign more significance to evidence that confirms a pattern and ignore or assign much less significance to evidence that does not.

  31. Friendly Fire 1994 Iraq No Fly Zone • Air Force F-15s • Air Force AWAC Plane • Army Blackhawk Helicopters Snook, Scott A. Friendly Fire: The Accidental Shootdown of U.S. Black Hawks Over Northern Iraq. Princeton, NJ: Princeton University Press, 2000. (Winner of the George R. Terry Book Award, Academy of Management, 2002.)

  32. They saw what they expected Army Black Hawk Hind

  33. A Patient with Chest Pain 68 year-old male with known coronary artery disease presents with chest pain, nausea and shortness of breath and a complaint of “I’m having another heart attack doc.”

  34. Anchoring • Tendency to rely too heavily on one piece of information when making decisions. OR • Inappropriate reference point

  35. Illusory Bias • Causation • Association • Background Noise

  36. Breast Implant Law LawOffices of Stephen M. Frailich Attention Womenwho have had breast implants and are having health problems. Do you have the following symptoms? • Chronic Headaches & Fatigue • Upper & Lower Back Pain • Pain in your Breast • Joint Pains • Muscle Pains • Unexplained Rashes • Hair loss • Swelling • Memory Loss

  37. Atypical Connective Tissue Disease Dear Mr. Frailich, “Your winning the $110,000.00 Dow Class Action claim for my wife, was a tremendous boost to our morale after my wife's suffering so many years with the symptoms of implant toxicity. We were also surprised to receive the claim check much earlier than your office predicted that we may.” 1/7/11  J.P. Grand Rapids, MI

  38. More Associations • Silver Dollars and Umbilical Hernias • Antibiotics and viral infections • Bed Rest and Premature Labor

  39. A Really Bad Duo • Unavoidable Risk • Information Cascade

  40. Cognitive Bias Teaching Points • Confirmation: Does everything fit? • Illusory: What is the real relationship? • Overconfidence: Did you find everything? • Anchoring, Availability, Attribution: What else could it be?

  41. Framing • Mental model that influences how we present an issue to others. • Influence of risk-aversion on decision making. Opportunity or Threat?

  42. Relative or Absolute Risk

  43. Chantix for Smoking Cessation • Chantix Representative • Long Term (1 year) quit rate with Chantix is 270% that of placebo • Welbutrin Representative Rate of serious Cardiovascular Events with Chantix was 25% higher than placebo The Medical Letter on Drugs and Therapeutics • August 22, 2011 (Issue 1371) p.65

  44. Metacognition • A method of introspection in which one is expected to contemplate or reflect on their own thinking to avoid cognitive errors. • A check and balance between intuition and analysis.

  45. Important Points • Disease is a movie, you may only have one scene. • Defensive Medicine is not Clinical Reasoning. • How we think, is what we will teach. • Let the students hear you “think out loud”.

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