enhancing thinking & learning via mechanism maps
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A teaching hospital of Harvard Medical School. Enhancing Thinking & Learning via Mechanism Maps. Richard M. Schwartzstein, MD David H. Roberts, MD Shapiro Institute for Education and Research Beth Israel Deaconess Medical Center HMS Academy. Education is at the heart of patient care. - PowerPoint PPT PresentationTRANSCRIPT
Enhancing Thinking & Learning via Mechanism Maps
Richard M. Schwartzstein, MD
David H. Roberts, MD
Shapiro Institute for Education and ResearchBeth Israel Deaconess Medical Center
HMS Academy
A teaching hospital of Harvard Medical School
Education is at the heart of patient care.
A teaching hospital ofHarvard Medical School
After this session, you will be able:
• To describe the underlying cognitive theory behind the use of concept maps and mechanism maps
• To use mechanism maps to foster linkage of basic and clinical science concepts
• To enhance teaching of analytical reasoning in the approach to clinical problems
A teaching hospital ofHarvard Medical School
How do we facilitate deep learning?Modified from Harasym et al. 2008
Surface Learning-- New info not linked to
previous knowledge-- Knowledge abundant but
disorganized-- Focus on memorization
and recall-- Learn concepts and facts
without reflection
Deep Learning-- Relates new knowledge to
previous knowledge-- Content organized into
coherent whole-- Focus on problem-solving;
synthesis, application, transfer-- Link concepts/principles to
everyday experience
A teaching hospital ofHarvard Medical School
Encoding and Retrieval of Information Influences Learning
Karpicke and Blunt, Science Express, 2011• “Activities that promote effective encoding,
known as elaborative study tasks, are important for learning”
• “Because each act of retrieval changes memory, the act of reconstructing knowledge must be considered essential to the process of learning”
A teaching hospital ofHarvard Medical School
Problem Solving and Neural Networks Adapted from Jung-Beeman et al., PLoS Biology, 2004
Problem solving relies on cortical networks for access to and use of information
Problems without obvious/immediate solutions require engagement of distinct neural and cognitive processes
These processes allow solvers to see connections that may have previously eluded them
A teaching hospital ofHarvard Medical School
Encourage inductive reasoning to enhance thinking
Modified from Pottier et al. Med Ed 2010
Inductive Reasoning Deductive Reasoning
A teaching hospital ofHarvard Medical School
What do Concept Maps incorporate?
A teaching hospital ofHarvard Medical School
Mechanistic Mapping“The mechanistic case diagram is a student constructed
tool whose objective is to trace, in stepwise form, the pathophysiologic mechanisms leading from underlying causes of disease (including genetic, microbiologic, and social) to the clinical signs and symptoms and psychosocial consequences described in a PBL case.”
Guerrero APS, Acad. Med. 2001;76:385–389
A teaching hospital ofHarvard Medical School
…and now, let’s try one!
A teaching hospital ofHarvard Medical School
Chief Complaint
PJ is a 51 year old woman with a one year history of intermittent abdominal pain who now presents with nausea, vomiting, and worsening abdominal pain.
A teaching hospital ofHarvard Medical School
HistoryPMH- Type II Diabetes- Hypertension- Rheumatoid Arthritis- Obesity- NO history of gallstones,
hypertriglyceridemia or prior pancreatitis
PSH
- Low-transverse abdominal scar c/w possible gynecologic surgery
Medications- Hydroclorothiazide- Metoprolol- Amlodipine- Cyclobenzaprine- Nabumetone- Fluticasone
FH - HTN- No FH GI malignancy/diseaseSH- Tob: 1ppd, duration uncertain- EtOH: 2-3 beers/day- Illicits: unknown
A teaching hospital ofHarvard Medical School
Initial Presentation• Vital signs notable for tachycardia to 110’s
What does this tell you? Is it specific? Sensitive?
– Increased sympathetic activity• Compensatory (hypovolemia)• Pathologic (Axis dysregulation)• Parallel (Pain)• Pharmacologic
– Decreased parasympathetic activity• Neurologic dysregulation• Pharmacologic
A teaching hospital ofHarvard Medical School
Initial Presentation Continued• CT abdomen revealed acute pancreatitis
– extensive peripancreatic inflamation – distended GB with no evidence of stones, – diverticulosis
• RUQ ultrasound– No stones or biliary duct dilation.
• Amylase 183• Lipase 157 • She was admitted to their medical service, made NPO, and
started on IV fluids for presumed mild pancreatitis
A teaching hospital ofHarvard Medical School
Deterioration at Outside Hospital
• Overnight, developed hypotension, acidemia, hyperglycemia, and extreme fever/hyperthermia
• Transferred to the OSH ICU for mechanical ventilation, central line placement, vasopressor support, and insulin and bicarbonate drips
A teaching hospital ofHarvard Medical School
Was her Tachycardia an early Warning Sign?
Stages of Intravascular Volume DepletionStage % Vol down CompensationBP UOP1 <15 Increase SVR Normal Normal2 15-30 Increase HR, SVR Normal Decreased3 30-40 Increase HR, SVR <100 Decreased4 40+ Increase HR, SVR <70 Absent
Adapted from Lawrence, Essentials of General Surgery and The American College of Surgeons ATLS guidelines
A teaching hospital ofHarvard Medical School
Labs Prior to Transfer
38125 94
10
15
2.8550
Calcium: 5.5 Phos: 2.0 Mag: 4.7(8.4-10.3) (1.6-2.6)
ABG pH 6.97 pCO2 55 pO2 121
AST 126 ALT 63 Alk Phos 95LDH 469 Alb 2.9 INR 1.2
Amylase 783 (from 183) Lipase 2000 ( from 157) CK 1090 Lactate 9.2
(0.3)
A teaching hospital ofHarvard Medical School
Condition on Arrival to BIDMCVS: T: 106.9 HR: 152 BP: 113/61 RR: 21 O2Sat: 93% Glucose 235• On Norepinephrine, bicarb and insulin drips• On Ventilator (FiO2 100% RR 24 VT 400 PEEP 10)
ABG: pH 7.06 pCO2 90 pO2 121 (from 6.97) (from 55) (stable)
Exam notable for: • ET tube properly positioned with bilateral breath sounds. • Abdomen firm, distended, and dull to percussion. • Extremities cool. No edema.
Na 145Cl 110HCO3 22
A teaching hospital ofHarvard Medical School
Admission CXR
Bladder pressure 1828
ABG Trend23:39 pH 7.06 pCO2 90 pO2 121 (FiO2 100% RR 24 Vt 400 PEEP 10)
00:19 pH 7.09 pCO2 95 pO2 106 (FiO2 100% RR 27 Vt 300 PEEP 10)
A teaching hospital ofHarvard Medical School
What’s going on Here?
Problem List:1. Hypotension2. Hypoxemic, hypercarbic respiratory failure3. Anion gap metabolic acidosis with overlying
respiratory acidosis4. Pancreatitis5. Acute Renal Failure…
A teaching hospital ofHarvard Medical School
Concept Map
Pancreatitis
Inflammatory Response, Cytokine Release
Increased vasculaturepermeability
Third Spacing
Poor tissueperfusion
Hypotension
AnaerobicMetabolism
Acidosis
Increased abdominalpressures
Decreased Chest-WallCompliance
HypercarbicResp
Failure
A teaching hospital ofHarvard Medical School
Why develop Shock in Pancreatitis?Hypovolemic Component:
– intravascular volume decreases by 19% in 2 hours– Decreases by 30% in 6 hours– Patients may require 10L fluid in initial 24 hours
Cardiogenic Component:– Initially, CI increases and SVR decreases (sepsis-like)– Later, cardiac function decreases
Distributive Component:– Inflammatory cytokines(IL-1, IL-6, TNFalpha) reduced SVR
Early volume-resuscitation lowers mortality
Yegneswaran et. al, Cardiovascular Manifestations of Acute Pancreatitis.J Crit Care 2011 Apr;26(2):225
Gardner et al. Faster rate of initial fluid resuscitation in severe acute pancreatitisdiminishes in-hospital mortality. Pancreatology 2009;9:770-76