A Curriculum in Clinical Reasoning

Dr Penny Lockwood MBChB MRGCP FRCGP MMEd

GP and Honorary Senior Lecturer University of Dundee

Introduction

uPresentationuWhy teach clinical reasoning?

uMoving from novice to expert

uRole and place of biomedical knowledge

uExperience, practice and simulation

uWho deliveries the curriculum

uManaging student expectations

uAssessment and student use of formulas

uWork in groupsuWhen should students move from the checklists to

more expert history taking?uHow can we provide opportunities for experience

and feedback on clinical reasoning skills early in the curriculum?

uWhat different opportunities in the curriculum for learning clinical reasoning.

uHow do we ensure the students have all the relevant knowledge prior to sessions on clinical reasoning

uDebrief and summarize

Why Teach Clinical Reasoningu To prevent errors

u To give students tools to deal with uncertainty

But clinician’s have always used clinical reasoning without it being taught.

Or have they?

Early Medicine and Curriculau Early clinicians named a set of symptoms- e.g

consumption

u Understanding of the pathology and science increased

u Clinicians started to work out the underlying cause for the patient’s presentation

u Firms

u Apprenticeship

Firms

Current Situation

Role modelling and being involved in patient care is importantuNow more structured curriculauLess time in apprenticeshipuJunior doctors hours- more disjointed

follow up of patients

Your position is indicated on the map and you have to decide the quickest and safest route off the hill.

https://osmaps.ordnancesurvey.co.uk/57.19577,-6.21118,18/pin

What factors make your decision making process easier and which factors make it difficult to make the right choice?

How would expertise in mountaineering help?

Novices

uNeed rules to start with

uFollow rules rigidly

uUse hypothetical deductive reasoning?

uUse inductive reasoning

uNeed metacognition to develop expertise

uConsider single concepts when dealing with cases

Experts

uUse fuzzy logicuUse non analytical reasoninguDraw on schema to helpu Intuitive decision makinguCan use several reasoning approaches

according to situationuCan use multiple concepts in one case

Moving from Novice to Expertu Developing schema helps produce expertise

u Experience is needed

u Practice and feedback

u Reflection and metacognition

u Different teaching approaches as the learner progresses

u Challenge- some learners progress faster than others

u Use cases that are not clear cut

Biomedical Knowledgeu Content Specificity

u Cognitive processes to solve problems domain specific

But I would not expect to be able to diagnose what is wrong with a car that is “not well”. I do not know what the possibilities are or what causes the tinkling sound!

This Photo by Unknown Author is licensed under CC BY-NC-SA

This Photo by Unknown Author is licensed under CC BY-NC-SA

Studies Indicating Biomedical Knowledge is Important

u Encapsulation theory

u Relevant biomedical knowledge related to clinical cases does not atrophy

u Being taught the medicine before seeing a case allows students to learn the clinical reasoning process

u Trying to reason through a case with out being taught the background knowledge can be confusing

Implications for Curriculum Design

u Clinical reasoning requires knowledge and cognitive ability

u In the early years students need to have the knowledge for the cases they work with

u In the junior years need to use cases where the possible diagnosis are conditions that have already been taught

u Keeping up with changes

Experience Practice and Simulation

u Need experience with many patients in multiple contexts

u Practicing the skill improves successu Allow them to make mistakesu Develop illness scriptsu Avoids cognitive overloadu Provide experiental learningu Use simulation to start and gradually increase

authenticityu Helps students to make a clear decision and then get

feedback

This Photo by Unknown Author is licensed under CC BY-NC-ND

Varying Teaching Approaches

u Change teaching approach as the student moves through the curriculum

u Schmidt and Mamede (2015) suggest:u Development in memory of detailed causal knowledge

explaining disease in terms of pathophysiological principles;

u Encapsulation of pathophysiological knowledge;

u Development of illness scripts.

Student Expectation

uStudent expectations should be managed

uThey expect clear answers after each case

uThey do not always prepare their knowledge before teaching sessions

uThey tend to try and take the shortcuts they see experts take

Example of Managing Student Expectations

“What I say to students is, you are watching somebody who’s

essentially an expert in it, somebody who is really good so

it’s like watching somebody parallel ski and then expecting

that you can suddenly do that without having to learn how to

ski yourself. You must go through steps in order to do that

so that’s the way I try to reconcile it with students, saying,

well actually these are experts. They’ve taken these

shortcuts because they’ve got years of expertise to know

that these shortcuts are (safe)” (tf4).

Assessment

uDrives learning

uQuestions that students ask is a surrogate end point

uAvoid buzz words or phrases

uUse cases whose symptoms do not point to a clear diagnosis

Group work

u When should students move from the checklists to more expert history taking?

u How can we provide opportunities for experience and feedback on clinical reasoning skills early in the curriculum?

u What different opportunities in the curriculum for learning clinical reasoning?

u How do we ensure the students have all the relevant knowledge prior to sessions on clinical reasoning?

Summary

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