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Franklin Square Hospital Center Baltimore, MD. Beyond Read More!. Incorporating Adult Learning Theory into Postgraduate Medical Education. Frederick Williams, MD. Learner Maturation. Minimum Acceptable Level. Competency. A. B. C. PGY1. PGY2. PGY3. Learning Objectives.
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Franklin Square Hospital Center Baltimore, MD Beyond Read More! Incorporating Adult Learning Theory into Postgraduate Medical Education Frederick Williams, MD
Learner Maturation Minimum Acceptable Level Competency A B C PGY1 PGY2 PGY3
Learning Objectives • Understand current concepts problem solving strategies derived from adult learning theory. • Appreciate the importance of knowledge organization/acquisition in problem-solving • Review how we as educators can facilitate more efficient and accurate problem-solving by the way we teach
Learner Maturation Data Gathering Accuracy Expert Novice
History Physical Exam Laboratory Data X-rays Diagnosis
Building Blocks of Problem Solving Inductive Reasoning Deductive Reasoning Pattern Recognition
Inductive Reasoning Case: 35 year old AA female with one day hx of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93%
Diff Dx: CAD Pneumonia Pericarditis PE Musculoskeletal Pleuritis GERD Inductive Reasoning Case: 35 year old AA female with one day hx of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93%
Inductive Reasoning Case: 35 year old AA female with one day hx of sharp, left-sidedchest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93% • Diff Dx: • CAD • Pneumonia • Pericarditis • PE • Musculoskeletal • Pleuritis • GERD
Inductive Reasoning Case: 35 year old AA female with one day hx of sharp, left-sidedchest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93% • Diff Dx: • CAD • Pneumonia • Pericarditis • PE • Musculoskeletal • Pleuritis • GERD
Inductive Reasoning Case: 35 year old AA female with one day hx of sharp, left-sidedchest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93% • Diff Dx: • CAD • Pneumonia • Pericarditis • PE • Musculoskeletal • Pleuritis • GERD
Inductive Reasoning • Single symptom driven data collection • Redundancy of information • Large amount of data • Success dependent on initial differential dx
Acute Pleuritic Chest Pain Deductive Reasoning: Defining the Syndrome Case: 35 year old AA female with one day hx of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93%
Acute Chronic Chest pain
Pleuritic Acute Chronic Acute Nonpleuritic Chest pain
Deductive Reasoning • Unit of Diagnosis is the SYNDROME • Initial Data gathering is to define the syndrome • More Efficient/Less data • each step excludes multiple dx possibilities • Key Skills Needed: Processing/Transformation of Symptoms Compare and Contrast Mentality
Processing Unprocessed Processed One day history Acute Sharp, worse with Pleuritic inspiration and coughing Occurring at rest Nonexertional
Temporal Processing Symptom Pattern Qualitative Descriptor Epidemiology Common Syndrome Thematic Summary Acute vs Chronic Progressive Colicky pain Immunocompetent Delirium, Shock, CHF Destructive thrombocytopenia without coagulopathy Examples of Processing Descriptive Summative
Recognition Pattern
Illness Scripts *Inc A-a Grad *Acute onset SOB *Pleuritic chest pain *Calf tenderness *hemoptysis *Travel Pulmonary Embolism
Travel? A-a Grad Calf Pain?
Pattern Recognition Case: 35 year old AA female with one day hx of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93%
Pattern Recognition Case: 35 year old AA female with one day hx of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93% Pulmonary Embolism
Pattern Recognition • Unit of Diagnosis is the Disease • Skills Required: Grouping of Processed Symptoms Compare and Contrast Mentality Understanding of Key Features Data Acquisition for missing features Experience
Sort information Search for Patterns Select key findings Pauci-clue, Long Differential Diagnosis Inductive Deductive Targeted Differential Diagnosis Clinical Information Single Diagnosis Immediate recognition of distinct pattern Pattern Recognition
Learner Maturation Data Gathering Accuracy Expert Novice
Learner Maturation 100% % Deductive Reasoning and Pattern Recognition % Inductive Reasoning 0% Novice Expert
Knowledge Organization • The development of sophisticated problem solving skills involves not only an increase in the number of facts but a change in the way those facts are stored and used. Georges Bordage, MD Ph.D.
Knowledge Organization Exercise I
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Knowledge Organization • Reduced Knowledge • Dispersed Knowledge • Elaborated Knowledge • Compiled Knowledge Bordage, et.al
Reduced: few facts, poorly organized Dispersed: many facts, poorly organized Elaborated: many facts, logically organized to facilitate forward thinking Compiled: robust repertoire of illness scripts Qualitative and Quantitative Differences
Group Exercise II • Review the Responses each learner makes to the morning report case presentation • Compare and contrast the different case analysis styles according to the questions posed • Identify what type of knowledge organization schema they are using
Dr. Red: Reduced ?? B12 Deficiency
Reduced Knowledge Structure • True Paucity of Accessible Knowledge • Unit of Dx: Single Clue • Can’t use additional facts: don’t help • If no trigger with single clue: give up • Logic: Random Guess (sometimes right!) • Illness scripts: sketchy, disorganized, anemic
Dr. Yellow: Dispersed SCC Guillain Barre ? ? Stroke ? ALS Hypo- K
Dispersed Characteristics • “Forest for the Trees” • Thorough problem list but no Processing • no syndrome identification • Unit of Diagnosis: Single Clue, Random Selection • Illness scripts: more facts than reduced but still no relational component
Elaborated/Compiled Learners: LMN HIV Myopathy Leg weakness ID MS TM SCC UMN HAM Myelo- pathy Rheum Brain
What Happens at a Node? X = The syndrome of lower extremity weakness Rhabdo Myopathy UMN reflex no sensory abn tone global distrib X myalgia toes stroke vs SCC M, S reflexes LMN distrib :asc,pn, rad GBS, Amyotrophy neuralgia
Elaborated/Compiled Features • Unit of Diagnosis: Symptoms Processed to Syndromes • Systematic Approach: • logical progress through a series of interconnected nodes which emphasize disease/syndrome relationships • Illness Scripts: Robust, Syndrome Centered • Understands Key Features
Not Helpful Dr. Red: Reduced Dr. Yellow: Dispersed Helpful Dr. Blue: Elaborated Dr. Green: Compiled Knowledge Organization Styles these are different organizational schemes: the learner does not need to progress through the reduced and dispersed phase to get to the elaborated or compiled phase
Can We Change The Way People Think and Learn? Reduced/Dispersed Elaborated/Compiled
Teach Residents to: • Process information • Rely on multiple symptoms • Identification of Syndromes • Compare and Contrast Diagnostic Triads • Teaches Key Features • Building block of memory network • Build Accurate and Robust Illness Scripts
Compare And Contrast Learning A method to encourage the development of forward thinking and pattern recognition
Goals of Compare and Contrast Learning • Encourage the recognition of and use of syndromes as the unit of diagnosis • Reinforce that within a given syndrome, all facts are not created equal • Teach residents to build illness scripts based on key and differentiating features and to seek out these features when reading
I. Read Vertically • Identify A Syndrome-Not a disease • Identify a Diagnostic Triad • Like diseases that can cause a specific syndrome • Complete Table • Syndrome Features: seen in all three • Distinguishing Features: seen in only 2/3 • Key Features: unique in this triad to a single dz