enhancing thinking & learning via mechanism maps

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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 A teaching hospital of Harvard Medical School Education is at the heart of patient care.

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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 Presentation

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Page 1: Enhancing Thinking & Learning  via Mechanism Maps

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.

Page 2: Enhancing Thinking & Learning  via Mechanism Maps

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

Page 3: Enhancing Thinking & Learning  via Mechanism Maps

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

Page 4: Enhancing Thinking & Learning  via Mechanism Maps

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”

Page 5: Enhancing Thinking & Learning  via Mechanism Maps

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

Page 6: Enhancing Thinking & Learning  via Mechanism Maps

A teaching hospital ofHarvard Medical School

Encourage inductive reasoning to enhance thinking

Modified from Pottier et al. Med Ed 2010

Inductive Reasoning Deductive Reasoning

Page 7: Enhancing Thinking & Learning  via Mechanism Maps

A teaching hospital ofHarvard Medical School

What do Concept Maps incorporate?

Page 8: Enhancing Thinking & Learning  via Mechanism Maps

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

Page 9: Enhancing Thinking & Learning  via Mechanism Maps

A teaching hospital ofHarvard Medical School

…and now, let’s try one!

Page 10: Enhancing Thinking & Learning  via Mechanism Maps

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.

Page 11: Enhancing Thinking & Learning  via Mechanism Maps

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

Page 12: Enhancing Thinking & Learning  via Mechanism Maps

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

Page 13: Enhancing Thinking & Learning  via Mechanism Maps

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

Page 14: Enhancing Thinking & Learning  via Mechanism Maps

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

Page 15: Enhancing Thinking & Learning  via Mechanism Maps

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

Page 16: Enhancing Thinking & Learning  via Mechanism Maps

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)

Page 17: Enhancing Thinking & Learning  via Mechanism Maps

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

Page 18: Enhancing Thinking & Learning  via Mechanism Maps

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)

Page 19: Enhancing Thinking & Learning  via Mechanism Maps

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…

Page 20: Enhancing Thinking & Learning  via Mechanism Maps

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

Page 21: Enhancing Thinking & Learning  via Mechanism Maps

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