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Diagnostic Reasoning “DR” Toolbox

Heather Hofmann, MD Department of Medicine

2017-18

for Hospitalist Faculty

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Goal Increase faculty familiarity with diagnostic reasoning principles and tools so as to

improve its teaching.

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Three Parts:

I: Introduction to Diagnostic Reasoning II: DR Toolbox III: Structured Reflection Exercise (SRE)

Part I: Introduction to Diagnostic Reasoning

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Learning Objectives

- Understand the “what” and “why” of Diagnostic Reasoning

- Recognize dual-process theory’s role in “how” we reason

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What is Diagnostic Reasoning?

- Clinical reasoning - The process of thinking and decision making, consciously & unconsciously

guide practice actions

chest pain STEMI in proximal LAD

abdominal pain acute appendicitis

25yo female G1P0, 2m gestation returns from Rio.

- Diagnostic reasoning: - The process of collecting & analyzing information

establish a diagnosis

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Why teach diagnostic reasoning?

- Incorrect diagnoses are often at the root of medical errors

- DR is a means to apply basic science to clinical problems

- Central to being a physician

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Patient’s perspective

What’s wrong with me?

Is it bad?

What can we do about it?

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Why now?

Never too early for practice

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From Novice to Expert

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How do we reason?

Information processing theory

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How do we reason?

Information processing theory: Dual process theory.

Analytical Conscious

Type/System 2

Slow

Effortful

Deliberative

Logical

Requires attention, self-control, time.

Hypothesis-driven, Bayesian (probability)

Non-analytical Unconscious

Type/System 1

Fast

Automatic

Involuntary

Emotional

Executes skilled response and

generates “intuition” with minimal effort

Pattern recognition (illness scripts)

Heuristics

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From Novice to Expert

Analytical

Non-Analytical

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Can you learn/improve diagnostic reasoning?

Nonanalytic diagnostic reasoning

Analytic diagnostic reasoning

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Caveats

Diagnostic reasoning is a skill that improves with practice

It is highly individualized—both by the physician and for each given patient case

An ever growing fund of knowledge is critical

Part II: Diagnostic Reasoning Toolbox

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Learning Objectives

- Review principles for teaching DR to students

- Define key terms in teaching DR

- Review tips for leading teaching session

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Principles for teaching DR to clinical students

1. Student should be familiar with typical presentations of common diseases. Start to incorporate atypical presentations of common diseases, gradually increasing complexity.

2. Explicitly discuss clinical reasoning processes during case discussions.

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Definitions

Illness script

Scheme induction

Problem lists

Problem representation/summary statement

Framework

Differential diagnosis

Scaffolds

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Definitions

Illness script

Scheme induction

Problem lists

Problem representation/summary statement

Framework

Differential diagnosis

Scaffolds

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Illness scripts

Mental constructs of disease manifestations.

“The internal rolodex of diseases.”

How we store disease prototype in order to then use it for pattern recognition.

Non-analytical Unconscious

Type/System 1

Fast

Automatic

Involuntary

Emotional

Executes skilled response and

generates “intuition” with minimal effort

Pattern recognition (illness scripts),

Heuristics

Odds are you have a lot of these, but students

have few, immature ones

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Illness scripts Non-analytical Unconscious

Type/System 1

Fast

Automatic

Involuntary

Emotional

Executes skilled response and

generates “intuition” with minimal effort

Pattern recognition (illness scripts),

Heuristics

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Definitions

Illness script

Scheme induction

Problem lists

Problem representation/summary statement

Framework

Differential diagnosis

Scaffolds

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Scheme induction

A systematic application of rules to narrow the differential diagnosis of a symptom, sign, or lab.

Analytical Conscious

Type/System 2

Slow

Effortful

Deliberative

Logical

Requires attention, self-control, time.

Hypothesis-driven, Bayesian (probability), Worst-case scenario,

EBM

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Definitions

Illness script

Scheme induction

Problem lists

Problem representation/summary statement

Framework

Differential diagnosis

Scaffolds

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Problem lists

Lawrence Weed

A mechanism to summarize the state of a patient’s health in written documentation.

Many uses.

They can evolve within a history and across encounters.

Warning: Don’t lose the big picture.

Features of Effective Problem Lists

Use precise language

Update and modify over time

Prioritize

Make associations between problems

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Definitions

Illness script

Scheme induction

Problem lists

Problem representation/summary statement

Framework

Differential diagnosis

Scaffolds

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Problem representation/summary statement/one-liner/Impression

The description of the patient’s presentation.

Example 1: Mr. Smith is a 64-year-old man with the ischemic cardiomyopathy who presents with a

two day history of gradual onset, worsening dyspnea on exertion and findings of hypoxia, bilateral

crackles, elevated JVP, and lower extremity edema.

Example 2: Ms. Jones is a 33-year-old woman with a history of heavy alcohol use and NSAID use

who presents with two days of severe, burning, and midepigastric abdominal pain and acute

melena. Her examination is notable for hemodynamic instability, soft, nontender abdomen with

normal bowel sounds, no organomegaly or jaundice, normal rectal exam, but positive stool heme

testing.

3 Critical Components of Problem Representation

Clinical context

Temporal pattern

Key clinical symptoms and exam findings that relate to presenting symptoms.

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Problem representation/summary statement/one-liner vs. illness script

Very similar! And use patients to build illness scripts!

Patient-specific vs. disease-specific.

Both benefit from semantic qualifiers.

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Definitions

Illness script

Scheme induction

Problem lists

Problem representation/summary statement

Framework

Differential diagnosis

Scaffolds

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Framework

A means of building differential diagnoses.

NOT patient-specific.

Examples: Worst-First Approach

Mnemonics (e.g., VINDICATE)

Organ System- or Anatomic-based

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Differential diagnosis

Potential etiologies of a given patient problem.

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Worst-First Framework

• Ask yourself: Is this life-threatening? Does this patient need to be in an ED?

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• Chest pain: ACS vs. Aortic Dissection vs. PE vs. esophageal rupture vs. other non-life threatening

• Dyspnea: MI vs. CHF vs. COPD vs. asthma vs. PTX vs. PE

• Abdominal pain: pancreatitis vs. perforated viscus vs. Mallory Weiss tear vs. cholangitis vs. GERD

• Hematochezia: variceal bleed vs. diverticulosis vs. hemorrhoids vs. colon cancer vs. brisk upper GI bleed

Worst-First Examples

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VINDICATE (mnemonic Framework)

V Vascular

I Infectious

N Neoplastic

D Drugs

I Inflammatory, Idiopathic

C Congenital

A Autoimmune/Allergic

T Traumatic (including psychological trauma)

E Endocrine

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Vascular • Stroke (ischemic/ hemorrhagic) • TIA • HTN encephalopathy

Infectious • Encephalitis • Meningitis • Sepsis

Neoplastic • 1’ or metastatic tumor

Drugs/Toxins • Overdose/ Withdrawal

Inflammatory • SIRS, vasculitis, pancreatitis,

endocarditis

Congenital • Epilepsy

Autoimmune • Seizure in lupus patient

Trauma • Subdural bleed

Endocrine • Hypo/hyperglycemia • Hypo/hypernatremia • Uremia, ammonia • Hyper/hypothyroid

VINDICATE for CC: Altered Mental Status

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Organ System or Anatomic-Based Approach

• Define complaint anatomically

• If systemic disease, identify specific anatomic involvement

• Be thorough

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Anatomic Approach to Chest Pain

Skin?

Muscle?

Ribs?

Pericardium?

Myocardium?

Coronary vessels?

Pleura?

Lung parenchyma?

Pulmonary vessels?

Esophagus?

By Henry Vandyke Carter - Henry Gray

(1918) Anatomy of the Human Body (See

"Book" section below)Bartleby.com:

Gray's Anatomy, Plate 492, Public

Domain,

https://commons.wikimedia.org/w/index.ph

p?curid=545522

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Definitions

Illness script

Scheme induction

Problem lists

Problem representation/summary statement

Framework

Differential diagnosis

Scaffolds

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Scaffolds: how to develop students’ reasoning skills.

OLD CARTS

Schema

Problem Lists

SRE

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Definitions

Illness script

Scheme induction

Problem lists

Problem representation/summary statement

Framework

Differential diagnosis

Scaffolds

Part III: Structured Reflection Exercise (SRE)

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Learning Objectives

- Review the evidence-based method for assessing diagnostic reasoning

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ACS

CAD risk factors

30 years old

Summary Increase faculty familiarity with diagnostic reasoning principles and tools so as to

improve its teaching.

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Three Parts:

I: Introduction to Diagnostic Reasoning II: DR Toolbox III: SRE

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Questions?

Heather Hofmann, MD hhofmann@uci.edu @HeatherNHofmann

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References

Gordon, D., & Guth, T. (2013). Clinical Reasoning in Medical Students : Retrieved from http://www.cordem.org/files/DOCUMENTLIBRARY/2013 AA/2013 Day Two/Deliberate Metacognition.pdf

Kearney-Strouse, J. (2015). Clinical reasoning now a ‘foundational basic science’ in medical education. ACP Hospitalist. https://acphospitalist.org/archives/2015/11/teaching-clinical-reasoning.htm

Khullar, D., Jha, A. K., & Jena, A. B. (2015). Reducing Diagnostic Errors — Why Now? New England Journal of Medicine, 363(1), 150923140040009. http://doi.org/10.1056/NEJMp1508044

Levin M, Cennimo D, Chen S, Lamba S. Teaching clinical reasoning to medical students: a case-based illness script worksheet approach. MedEdPORTAL Publications. 2016;12:10445.

Modi, J. N., Gupta, P., & Singh, T. (2015). Teaching and Assessing Clinical Reasoning Skills. Indian Pediatrics, 52(9), 787–794. http://doi.org/10.1007/s13312-015-0718-7

Outpatient Diagnostic Errors Affect 1 in 20 U.S. Adults, AHRQ Study Finds. Content last reviewed April 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsroom/press-releases/2014/diagnostic_errors.html

Toy, E., & Patlan, J. (2012). Case Files Internal Medicine.

Trowbridge, R., Rencic, J., & Durning, S. J. (Eds.). (2015). Teaching Clinical Reasoning. ACP.

Wolpaw, T. M., Papp, D. R., & Klara, K. (2016). Academic Medicine : SNAPPS : A Learner ‐ centered Model for Outpatient Education, 78(9), 1–7.