teaching clinical reasoning

Teaching Clinical ReasoningTeaching Clinical ReasoningJennifer Jackson, MDWake Forest School of Medicine

Ronald Silvestri, MDHarvard Medical School

Goals & ObjectivesGoals & Objectives

Discuss clinical reasoning terminology

Describe cognitive models of clinical reasoning

Discuss instructional strategies for helping students develop their clinical reasoning skills throughout their curriculum

Take home to your institutions practical ideas for how to improve the teaching of clinical reasoning to your students

Discuss clinical reasoning terminology

Describe cognitive models of clinical reasoning

Discuss instructional strategies for helping students develop their clinical reasoning skills throughout their curriculum

Take home to your institutions practical ideas for how to improve the teaching of clinical reasoning to your students

Why teach students about clinical reasoning?Why teach students about clinical reasoning?

Diagnostic errors are frequent. Estimates: 10-15% Common occurrence in all fields of medicine

Diagnostic errors have major consequences. 2nd leading cause of adverse events, among

medical errors Associated with higher morbidity than other

medical error types

Diagnostic errors are frequent. Estimates: 10-15% Common occurrence in all fields of medicine

Diagnostic errors have major consequences. 2nd leading cause of adverse events, among

medical errors Associated with higher morbidity than other

medical error types

Why teach students about clinical reasoning?Why teach students about clinical reasoning?

Thinking about how we reason makes us more effective clinicians.

- When clinicians are forced to rethink their instinctive responses in solving complex cases, they make fewer diagnostic errors.

Teaching novices strategies to avoid cognitive errors can shorten their road to attainment of expertise.

Thinking about how we reason makes us more effective clinicians.

- When clinicians are forced to rethink their instinctive responses in solving complex cases, they make fewer diagnostic errors.

Teaching novices strategies to avoid cognitive errors can shorten their road to attainment of expertise.

THE LINGOTHE LINGOClinical Reasoning SkillsClinical Reasoning Skills

Clinical Reasoning (“Clinical Cognition”)Clinical Reasoning (“Clinical Cognition”)

“The range of strategies that clinicians use to generate, test, and verify diagnoses, to assess the benefits and risks of tests and treatments, and to judge the prognostic significance of the outcomes of these cognitive achievements”

- Kassirer 2010

“The range of strategies that clinicians use to generate, test, and verify diagnoses, to assess the benefits and risks of tests and treatments, and to judge the prognostic significance of the outcomes of these cognitive achievements”

- Kassirer 2010

Problem RepresentationProblem Representation

A physician’s evolving sense of the clinical picture; a way of describing a specific case in abstract terms (“one liner”)- e.g., full-term newborn with severe, acute

respiratory distress

Components:- Patient demographics- Clinical features from the history and PE- Semantic qualifiers (severe vs. mild; acute vs.

chronic; unilateral vs. bilateral)

A physician’s evolving sense of the clinical picture; a way of describing a specific case in abstract terms (“one liner”)- e.g., full-term newborn with severe, acute

respiratory distress

Components:- Patient demographics- Clinical features from the history and PE- Semantic qualifiers (severe vs. mild; acute vs.

chronic; unilateral vs. bilateral)

A mental representation of the important elements of an illness- e.g., strep throat: acute, febrile illness with

exudative tonsillitis

The same illness script may be linked to more than one problem representation (i.e., different clinical presentations of the same disease).

Developed by medical knowledge and refined through clinical experience

A mental representation of the important elements of an illness- e.g., strep throat: acute, febrile illness with

exudative tonsillitis

The same illness script may be linked to more than one problem representation (i.e., different clinical presentations of the same disease).

Developed by medical knowledge and refined through clinical experience

Illness ScriptIllness Script

Includes:- Pathophysiology- Who gets it - Key signs and

symptoms- Duration/pattern of

symptoms

Includes:- Pathophysiology- Who gets it - Key signs and

symptoms- Duration/pattern of

symptoms

Illness ScriptIllness Script

Clinical Problem-Solving, Catherine Lucey, MD, UCSF (http://vimeo.com/)

Cognitive Models of Clinical ReasoningCognitive Models of Clinical Reasoning

Dual-processing theory: 2 distinct modes of thinking occur when clinicians reason:

Intuitive (non-analytic) reasoning: “gut reaction”—impulsive, effortless, reflexive

- Pattern recognition- Highly context dependent- Error prone

Analytical reasoning: slow, explicit, deliberate, purposeful effort to solve a problem

- Hypothetico-deductive- Generally more reliable

Dual-processing theory: 2 distinct modes of thinking occur when clinicians reason:

Intuitive (non-analytic) reasoning: “gut reaction”—impulsive, effortless, reflexive

- Pattern recognition- Highly context dependent- Error prone

Analytical reasoning: slow, explicit, deliberate, purposeful effort to solve a problem

- Hypothetico-deductive- Generally more reliable

“Looks like a duck”

Dual-Processing TheoryDual-Processing Theory

The clinical reasoning process is dynamic.- Intuitive and analytic reasoning modes interact with

one another.- Clinicians “toggle” back and forth between the 2

modes in making decisions.

The clinical reasoning process is dynamic.- Intuitive and analytic reasoning modes interact with

one another.- Clinicians “toggle” back and forth between the 2

modes in making decisions.

Eva, 2004

Analytic mode can override the intuitive mode, and vice versa.

Repeated presentations to the analytic mode will eventually result in pattern recognition default to the intuitive mode.

Novices tend to spend more time in the analytic mode, whereas experienced clinicians spend more time in the intuitive mode.

Analytic mode can override the intuitive mode, and vice versa.

Repeated presentations to the analytic mode will eventually result in pattern recognition default to the intuitive mode.

Novices tend to spend more time in the analytic mode, whereas experienced clinicians spend more time in the intuitive mode.

Dual-Processing TheoryDual-Processing Theory

During a patient encounter, expert clinicians gather data based on their hypotheses about the patient’s symptoms.

Focused history and review of systems

Hypothesis-driven physical exam- More effective in detecting PE findings and

establishing a diagnosis than doing a survey exam without a diagnosis in mind

During a patient encounter, expert clinicians gather data based on their hypotheses about the patient’s symptoms.

Focused history and review of systems

Hypothesis-driven physical exam- More effective in detecting PE findings and

establishing a diagnosis than doing a survey exam without a diagnosis in mind

Hypothesis-Driven Data GatheringHypothesis-Driven Data Gathering

Differential diagnosis formation is iterative…

Hypothesis-Driven Data GatheringHypothesis-Driven Data Gathering

Chief complaint, patient demographics

Initial problem representation

Initial hypotheses

Scanning for illness scripts

Gather data(history, PE, labs)

Analyze/ synthesize data,

refine the problem representation

Refine diagnostic hypotheses

(differential dx)

Scanning for illness scripts, key features

Working diagnosis

Before seeing patient

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - During patient encounter

MetacognitionMetacognition

A method of introspection in which one contemplates or reflects on one’s own thinking; i.e., thinking about thinking

“It distinguishes…the thinking of experts from that of non-experts.”

- Croskerry 2003

A method of introspection in which one contemplates or reflects on one’s own thinking; i.e., thinking about thinking

“It distinguishes…the thinking of experts from that of non-experts.”

- Croskerry 2003

Effective metacognition involves:-Awareness of the learning process—knowing when a piece of information is important enough to commit to memory

-Recognition of the limitations of memory

-Ability to step back from the immediate problem at hand and appreciate the broader picture

-Capacity for realistic self-critique and self-monitoring

-Ability to actively select a strategy to deal with problems in decision-making—a deliberate cognitive intervention in the thinking process

Effective metacognition involves:-Awareness of the learning process—knowing when a piece of information is important enough to commit to memory

-Recognition of the limitations of memory

-Ability to step back from the immediate problem at hand and appreciate the broader picture

-Capacity for realistic self-critique and self-monitoring

-Ability to actively select a strategy to deal with problems in decision-making—a deliberate cognitive intervention in the thinking process

MetacognitionMetacognition

TEACHING METHODS & STRATEGIESTEACHING METHODS & STRATEGIES

Clinical Reasoning SkillsClinical Reasoning Skills

Coming…..

Small Group DiscussionSmall Group Discussion

Your curriculum revision subcommittee is charged with optimizing the teaching of clinical reasoning

1. What specific educational experiences and curricular changes would you propose & where?

2. Which of these changes are possible in the near term vs. intermediate term in your institution?

3. What are the obstacles to your students improving their clinical reasoning skillfulness?

Your curriculum revision subcommittee is charged with optimizing the teaching of clinical reasoning

1. What specific educational experiences and curricular changes would you propose & where?

2. Which of these changes are possible in the near term vs. intermediate term in your institution?

3. What are the obstacles to your students improving their clinical reasoning skillfulness?

Large Group DiscussionLarge Group Discussion

Each table takes 5 minutes to report its proposed educational experiences, curricular changes, obstacles, etc.

Large group exchange of ideas

Each table takes 5 minutes to report its proposed educational experiences, curricular changes, obstacles, etc.

Large group exchange of ideas

TEACHING METHODS & STRATEGIESTEACHING METHODS & STRATEGIES

Clinical Reasoning SkillsClinical Reasoning Skills

Clinical Reasoning Starts at the Bedside Clinical Reasoning Starts at the Bedside

Sufficiently detailed & discriminating H&P

Think “What’s going on & what’s causing it” from the beginning of the HPI

Generate hypotheses as to potential causes of the problem

Test these hypotheses during H&P, seeking evidence of “clusters” of sx and signs pointing to various hypotheses amidst HTT exam

Allow hypotheses to be refined as new H&P data obtained

Use illness scripts, prior experience, or Dx props

Sufficiently detailed & discriminating H&P

Think “What’s going on & what’s causing it” from the beginning of the HPI

Generate hypotheses as to potential causes of the problem

Test these hypotheses during H&P, seeking evidence of “clusters” of sx and signs pointing to various hypotheses amidst HTT exam

Allow hypotheses to be refined as new H&P data obtained

Use illness scripts, prior experience, or Dx props

Strategies for Teaching Clinical Reasoning


“VINDICATEM-P”: pathophysiology categories- Vascular- Infectious/Inflammatory- Neoplastic- Degenerative- Intoxication- Congenital/Hereditary- Autoimmune- Traumatic- Endocrine- Metabolic/Nutritional- Psychologic/Psychiatric

“VINDICATEM-P”: pathophysiology categories- Vascular- Infectious/Inflammatory- Neoplastic- Degenerative- Intoxication- Congenital/Hereditary- Autoimmune- Traumatic- Endocrine- Metabolic/Nutritional- Psychologic/Psychiatric

Create a Pathophysiologic vs. Anatomic Grid to help in DDx

Create a Pathophysiologic vs. Anatomic Grid to help in DDx

Ex: for Chest Pain think VINDICATEM for each site below Skin Ribs and muscle Pleura Pericardium Myocardium Endocardium Lungs (bronchi, vessels, parenchyma) Esophagus Aorta Spine and exiting nerves

Ex: for Chest Pain think VINDICATEM for each site below Skin Ribs and muscle Pleura Pericardium Myocardium Endocardium Lungs (bronchi, vessels, parenchyma) Esophagus Aorta Spine and exiting nerves

The Student First Has to Know about Problem Lists and Differential Dx

The Student First Has to Know about Problem Lists and Differential Dx

A “Problem” is any abnl sx, sign, illness, lab/imaging or constellation of them that makes clinico-pathophysiologic sense

A DDx is list of or paragraph of possible diagnoses or processes…

That explains a particular problem…

In this particular patient…

That includes data for & against each dx…

And is ordered according to likelihood

A “Problem” is any abnl sx, sign, illness, lab/imaging or constellation of them that makes clinico-pathophysiologic sense

A DDx is list of or paragraph of possible diagnoses or processes…

That explains a particular problem…

In this particular patient…

That includes data for & against each dx…

And is ordered according to likelihood

Strategies for Teaching Clinical Reasoning: After the Bedside – Student Next Steps

Strategies for Teaching Clinical Reasoning: After the Bedside – Student Next Steps

Assemble data into coherent presentation Step back, review, reflect, read & create Problem List Focus on problem(s) needing diagnosis or cause Create a DDx of each problem

Use pathophys. knowledge & prior clinical experience Assess defining & discriminating features Weigh sensitivity & specificity of various clinical findings Consider pre-test probabilities

Write down further actions to narrow DDx (tests/Rx)

Assemble data into coherent presentation Step back, review, reflect, read & create Problem List Focus on problem(s) needing diagnosis or cause Create a DDx of each problem

Use pathophys. knowledge & prior clinical experience Assess defining & discriminating features Weigh sensitivity & specificity of various clinical findings Consider pre-test probabilities

Write down further actions to narrow DDx (tests/Rx)

Teaching Clinical ReasoningTeaching Clinical Reasoning

Early meaningful mentored clinical exposure Allow students to PRACTICE these skills on their

own patient cases, and do it often! Use current “unknown dx” cases and return to

those cases where the dx finally made Introduce the basic concepts of problem

representations, illness scripts, and dual-processing.

Discuss possible cognitive errors that can occur (use real examples) and methods for avoiding them.

Early meaningful mentored clinical exposure Allow students to PRACTICE these skills on their

own patient cases, and do it often! Use current “unknown dx” cases and return to

those cases where the dx finally made Introduce the basic concepts of problem

representations, illness scripts, and dual-processing.

Discuss possible cognitive errors that can occur (use real examples) and methods for avoiding them.



CARD: variations of clinical presentation types- Common diseases- Atypical presentation of a disease- Rare diseases- “Don’t miss” diseases

CARD: variations of clinical presentation types- Common diseases- Atypical presentation of a disease- Rare diseases- “Don’t miss” diseases



SEA TOW - Avoiding Errors of Omission Second Opinion…Do I need one?Eureka Moment…Is this a pattern recognition dx?Anti-evidence…Is there anything refuting the dx?Thinking over my thinking…Have I done it?Overconfident…Am I?What else… could I be missing?

Williams,PA. Society for Medical Decision Making 2010

SEA TOW - Avoiding Errors of Omission Second Opinion…Do I need one?Eureka Moment…Is this a pattern recognition dx?Anti-evidence…Is there anything refuting the dx?Thinking over my thinking…Have I done it?Overconfident…Am I?What else… could I be missing?

Williams,PA. Society for Medical Decision Making 2010

- Get a commitment: “what do you think is going on in this case?”

- Probe for supporting evidence: “What led you to that conclusion?”

- Do a Wrap up for “adequacy” and “coherence” of case discussion

- Teach 1-2 general rules that will apply to other situations

- Reinforce what was done well

- Correct mistakes

- Get a commitment: “what do you think is going on in this case?”

- Probe for supporting evidence: “What led you to that conclusion?”

- Do a Wrap up for “adequacy” and “coherence” of case discussion

- Teach 1-2 general rules that will apply to other situations

- Reinforce what was done well

- Correct mistakes



Guidebook for Clerkship Directors, 4th Ed.by Bruce Morgenstern

•Lots of additional examples of clinical reasoning exercises for all levels of medical students

Guidebook for Clerkship Directors, 4th Ed.by Bruce Morgenstern

•Lots of additional examples of clinical reasoning exercises for all levels of medical students



ReferencesReferences Croskerry P, Nimmo GR. Better clinical decision making and reducing diagnostic error. J R Coll

Physicians Edinb 2011; 41:155–62. Croskerry P. The importance of cognitive errors in diagnosis and strategies to prevent them.

Acad Med 2003; 78:1–6. Croskerry P. Cognitive and affective dispositions to respond. In: Croskerry P, Cosby KS,

Schenkel S et al., editors. Patient safety in emergency medicine. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 219–27.

Croskerry P. Cognitive Forcing Strategies in Clinical Decisionmaking. Annals of Emergency Medicine 2003;41(1):110-118.

Croskerry P, Abbass A, Wu A. Emotional Influences in Patient Safety. J Patient Saf 2010;6(4):1-7.

Hogarth RM. Educating intuition. Chicago: University of Chicago Press; 2001. Elder L, Paul R. Critical thinking development: a stage theory with implications for instruction.

Tomales, CA: Foundation for Critical Thinking; 2010. Available from: http://www.criticalthinking.org/page.cfm?PageID=483&CategoryID=68.

Kassirer JP. Teaching Clinical Reasoning: Case-Based and Coached. Academic Medicine 2010;85(7): 1118-1124.

Atkinson K, Ajjawi R, Cooling N. Promoting clinical reasoning in general practice trainees: role of the clinical teacher. The Clinical Teacher 2011; 8: 176-180.

Rencic J. Twelve tips for teaching expertise in clinical reasoning. Med Teach 2011; 33:887-892 Eva KW. What every teacher needs to know about clinical reasoning. Med Educ 2004; 39: 98-

106

Croskerry P, Nimmo GR. Better clinical decision making and reducing diagnostic error. J R Coll Physicians Edinb 2011; 41:155–62.

Croskerry P. The importance of cognitive errors in diagnosis and strategies to prevent them. Acad Med 2003; 78:1–6.

Croskerry P. Cognitive and affective dispositions to respond. In: Croskerry P, Cosby KS, Schenkel S et al., editors. Patient safety in emergency medicine. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 219–27.

Croskerry P. Cognitive Forcing Strategies in Clinical Decisionmaking. Annals of Emergency Medicine 2003;41(1):110-118.

Croskerry P, Abbass A, Wu A. Emotional Influences in Patient Safety. J Patient Saf 2010;6(4):1-7.

Hogarth RM. Educating intuition. Chicago: University of Chicago Press; 2001. Elder L, Paul R. Critical thinking development: a stage theory with implications for instruction.

Tomales, CA: Foundation for Critical Thinking; 2010. Available from: http://www.criticalthinking.org/page.cfm?PageID=483&CategoryID=68.

Kassirer JP. Teaching Clinical Reasoning: Case-Based and Coached. Academic Medicine 2010;85(7): 1118-1124.

Atkinson K, Ajjawi R, Cooling N. Promoting clinical reasoning in general practice trainees: role of the clinical teacher. The Clinical Teacher 2011; 8: 176-180.

Rencic J. Twelve tips for teaching expertise in clinical reasoning. Med Teach 2011; 33:887-892 Eva KW. What every teacher needs to know about clinical reasoning. Med Educ 2004; 39: 98-

106

• Take home points from today

• How can or should DOCS as an organization advance the teaching of clinical reasoning?

• Can we or should we try to do it alone? If not, who should our partners be?

• Take home points from today

• How can or should DOCS as an organization advance the teaching of clinical reasoning?

• Can we or should we try to do it alone? If not, who should our partners be?

Wrap UpWrap Up

teaching clinical reasoning

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