“ we’re pretty sure it’s the west nile virus.”
DESCRIPTION
“ We’re pretty sure it’s the West Nile virus.”. Assessment of Diagnostic Reasoning and Clinical Thought Chart Stimulated Recall. Clinical Judgment/Reasoning. The cognitive engine that drives problem-solving and decision-making. www.chinesenursing.org/openAccess/sn331/html/doc/cyber-M1_ - PowerPoint PPT PresentationTRANSCRIPT
“We’re pretty sure it’s the West Nile virus.”
Assessment of Diagnostic Reasoning and Clinical
ThoughtChart Stimulated Recall
Clinical Judgment/Reasoning
The cognitive engine that drives problem-solving and decision-making.
www.chinesenursing.org/openAccess/sn331/html/doc/cyber-M1_students.pdf clinical reasoning definition
Critical Thinking Good Thinking
– Sensitivity• Interest in gaining
more information• Seeking alternatives
– Inclination• Willing to invest
energy in thinking the matter through
– Ability• Possess the
cognitive ability
“Bad Thinking” – “cognitive misers”– Chose to take mental
shortcuts, engage in heuristic thinking,
– without interest in “good thinking”
Krupat 2011
Clinical Judgment/Reasoning
Internal process Trainees and faculty need ways to
externalize this process Programs need to identify assessment
methods that document growth and competency in this skill
Key Elements of Diagnostic Reasoning
Patient’s story
Data acquisition
Accurate “problem representation”
Generation of hypothesis
Search for and selection - illness script
Diagnosis
Knowledge
Context
Experience
Bowen JL. NEJM; 2006: 2217
Clinical Reasoning
Graber¹ adverse event study:– Most errors combination of individual and systems
factors– Average 5.9 system +/- cognitive error per case
“Cognitive factors”:– 320 cognitive factors in 74 cases– 45 due to faulty data gathering– 264 due to faulty synthesis (problem representation)
¹ Arch Intern Med. 2005; 165: 1493.
Problem Representation
Non- analytical - The behavior of experts– Pattern Recognition illness scripts
– Heuristics• The rapid non-analytic mental shortcuts that
humans use to recognize and categorize things.
Analytical - The work of early learners– Hypothesis based deductive reasoning
– The default when a pattern is not apparent
Clinical presentation
No clearPattern
Pattern identified
Hypothesis basedDeductive reasoning
(Analytic)
Illness scriptSelected
(Non-analytic)
You evaluate a 78-year-old male with a 2-week history of joint pain beginning after
cardiac catheterization. Both knees and one wrist are red, painful, and swollen. X-ray is
pending. No fever, weight loss or malaise, and recent
labs reveal an ESR of 50. Past medical history includes CAD and hypothyroidism.
Processed Problem Representation
78-year-old (ELDERLY) male for evaluation of a 2-week (SUBACUTE) history joint pain. Symptoms began 1 week after a cardiac catheterization (RECENT MEDICAL INTERVENTION). Both knees and one wrist
(OLIGO-ARTICULAR). He has no fever, weight loss, or malaise (NON-SYSTEMIC).
Recent labs are significant for an ESR of 50 (INFLAMMATORY).
Pattern – illness script
ElderlySubacuteRecent medical
interventionOligoarticularNon-systemic Inflammatory
Pseudogout
Heuristics Availability
– Diagnose disease that are familiar or striking • HTN is due to pheochromocytoma
Recency– Diagnosis is proposed because it was recently seen
• I just read about ----
Anchoring– Weight data that supports your diagnosis more than
data that does not
The Art of Clinical Questioning
Promoting/Probing Clinical Reasoning
– Minimize overuse of recall questions
– Use compare and contrast learning
– Avoid “what am I thinking now?”
– Encourage identification of key features of an illness
Chart-Stimulated Recall
Uses the medical record as a reference point for structured clinical questioning
Specifically targets clinical reasoning Developed by the ABEM High correlation between examiners Reliable enough with 3 cases for pass/fail
determinations Ultimately dropped by ABEM because of cost
and time requirement
Chart Stimulated Recall
Requirements:– Conducted by medical faculty– Faculty development needed– Ideally, the medical record is reviewed
in advance to identify specific questions
Chart Stimulated Recall
Benefits
– Inexpensive and easy to teach
– Uses patients/clinical scenarios familiar to the trainee (context of care)
– Allows examiner to assess problem solving and interpretation skills
– Adaptable to multiple learner levels
Small Group Exercise
Review this resident note. The resident is on a one month
geriatric rotation. Are there opportunities to explore
the resident’s diagnostic reasoning?
Questioning Recall
– What, how, why?• What is the significance of dip stick positive hematuria in
the absence of RBCs? Analysis/synthesis
– Demonstrate reasoning• There are multiple causes for falls in the elderly, what
features of this presentation suggest volume loss/anemia as opposed to drug side effect?
Application– Apply knowledge/skills/attitudes to a specific presentation
• In the setting of renal insufficiency with a history of diabetes, new NSAID use, and and polymyosiitis, how would you distinguish determine etiology?
Overall Note:Clarity____________________________________Organization ____________________________________Documentation____________________________________Internal Consistency - Identify any disconnects in the history and physical.
Based upon the history and physical?
Are you comfortable responding to a change in clinical status
Appropriate incorporation of labs in diagnosis and plan
Documented thought process for treatment plan
Treatment appropriate for diagnosis
Documented thought process for differential diagnosis
Accurate differential diagnosis
Appropriate analysis of lab data
Appropriate Physical
Appropriate History
Delineation of sick vs non sick
Clear Chief Complaint
N/ANOYESPlease check ONLY ONE box per statement
Based upon the history and physical?
Are you comfortable responding to a change in clinical status
Appropriate incorporation of labs in diagnosis and plan
Documented thought process for treatment plan
Treatment appropriate for diagnosis
Documented thought process for differential diagnosis
Accurate differential diagnosis
Appropriate analysis of lab data
Appropriate Physical
Appropriate History
Delineation of sick vs non sick
Clear Chief Complaint
N/ANOYESPlease check ONLY ONE box per statement
Night Float CSR
0
1
2
3
4
5
6
7
8
9
10
Score
Jul Au Se Oc No De Ja Fe
Academic Month
Table 3 Resuls of Random History and Physical Review
How might your program utilize a
CSR exercise?
Donobedian Framework
Schematic representation of a system Every system has a structure and a process
that processes that produce an outcome
S + P = O You need to consider each of these
components in your assessment system!
Donobedian Framework
S + P = O
Night float MR + CSR = Evaluation of trainee clinical thought/diagnostic reasoning and a documented educational experience on night float rotation
Questions