teaching clinical reasoning and novice to expert
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Teaching clinical reasoning and novice to expert
AusDEM Workshop 2019
A/Prof Julia Harrison
• How did you learn to reason clinically?
• How is clinical reasoning generally taught in your craft group?
• Are you involved in teaching it?
• If so, how do you teach it?
Activity
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What is clinical reasoning?
• Assessing a patient and making decisions about management
1. Diagnostic reasoning
2. Management decision making
What clinical reasoning strategies are you aware of?
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Some clinical reasoning strategies
• Rules of thumb / heuristics• Pattern recognition / Gestalt• Hx, Ex, Dx, Ddx, Mx,• Hypothetico-deductive method• Exhaustive method• Protocols, pathways, guidelines, decision rules• 2nd opinion / discussion• Clinical reasoning sandwich
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Forms of reasoning
• Non–analytic System 1
• Unconscious and automatic
• Fast
• Effortless
• Pattern recognition
• Intuition
• Requires experience
• Difficult to put into words
• not distractable
• Analytic System 2
• Conscious and controlled
• Slow
• Effortful
• Exhaustive method
• Hypothetico-deductive method
• Requires knowledge
• Easy to put into words
• distractable
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What is 15 X 26?
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Non-analytic reasoning• The Human brain is strongly wired to look for patterns
• It occurs unconsciously all the time
• Reinforced with exposure/experience
• Feedback improves accuracy and hastens progress
• Important part of clinical reasoning
• How can educators facilitate this form of reasoning?
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Analytic thinking
Exhaustive method
• Detective
Hypothetico-deductive
• Mechanic
What happens over time
Experienced Doctor
Exhaustive method
Pattern recognition
Hypothetico-deductive method
3rd year medical student
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Problem based Hx, Ex, Dx, Mxin the setting of work
Problem based Hx, Ex, Dx, Mx
Systems based Hx , Ex, Dx
Conditions and how they manifest (illness scripts)
Basic sciences, anat, phys, pharm ,path,
systems
Representations of clinical reasoning
• Dual Process Theory(Patrick Croskerry)
• Dynamic Decision Making
(Mica Endsley)
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The dual process theoryContext
Ambient conditions
Modular responsivity
Task difficulty
Task ambiguity
Affective state
Education
Training
Critical thinking
Logical competence
Rationality
Feedback
Intellectual ability
Pattern
Recognition
Repetition
Rational
override
Dysrationalia
overrideCalibration Response
Patient
Safety
Problem
Pattern
Processor
RECOGNIZED
NOT
RECOGNISED
System
1
System
2
Pat Croskerry
Gather
information
Make sense
of the
information
Predict
what could
happen
Make a
decision
Decision making in the real world
(Dynamic decision making):
Mica Endsley (2004)
Simplified version of her model of
situation awareness20
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Gather
information
Make sense
of the
information
Predict what
could
happen
Decide
what to do
All steps require a solid knowledge-base in the medical
sciences: anatomy, physiology, pathology, pharmacology.
Effective clinical reasoning is dependant on clinical and
cognitive skills in all four stages
Prerequisites for the development of these skills are
KNOWLEDGE and EXPERIENCE
There are pitfalls at each stage
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Basic sciences
Conditions
Patient presentations
: Hx, Ex, Ix
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Novice to Expert
Are some people better at clinical reasoning than others?
How can you tell?
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2 stories
• 3rd year medical student assessing a patient in the ED
• Fireman saving the lives of his crew(Gary Klein. Sources of Power – How people make decisions. 1998)
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3 short cases
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1. An intern forgets her medical training
• 58 yr old lady with left leg and hip pain
• Plan following assessment:• US to exclude DVT
• Xray looking for OA of hip because there is pain on mvt of the joint and no Hxof trauma or strain.
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Experienced doctor sees a cellulitic looking leg and knows to palpate the inguinal nodes and check the temperature -nodes are very tender and enlarged and patient has a fever.
Dx of cellulitis confirmed, DVT and arthritis are no longer likely.
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Learning from the case
• A good examination matters
• Don’t forget the basics eg “look, feel, move”
• Junior clinicians need to be more thorough in their assessments or they will miss things. This is because their pattern recognition is in the early stages of development.
• Experienced clinicians are better at recognising likely possibilities and honing in on relevant information.
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2. An ED reg misses an easy diagnosis
ED registrar sees middle aged man with a painful red swollen elbow. Concerned re septic arthritis.
No fever. Rings orthopaedic registrar - advised to take bloods and aspirate the joint.
ED registrar not sure where to put the needle.
Asks ED consultant to help.
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Consultant notes localised redness and tenderness around lateral epicondyle, patient still able to flex and extend elbow.
Consultant considers tennis elbow and asks about repetitive arm movementsPatient spent 6 hours delivering telephone books the day before.
R.I.C.E. patient reassured and septic arthritis no longer a consideration
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What’s going on?
• Junior reg has never seen tennis elbow or septic arthritis of the elbow (book knowledge only), senior doctor has seen both
• Lots of teaching on the importance of not missing a septic joint, not much on tennis elbow
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Learning from the case
• Experience counts for a lot
• While you are waiting for more experience thoroughness is your friend
3. Beginner’s blindness
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• Junior reg sees a 21 year old man with a swollen painful hand after punching someone
• She diagnoses a punch fracture using pattern recognition, but can’t see the fracture on XRAY?
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• Consultant “sees” a different pattern…
• Painful swollen hand following punching
• Patient presenting 3 days post punch
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• Relying on pattern recognition can be error prone -especially for inexperienced staff.
• Pattern recognition becomes more sophisticated with experience
• Juniors need to be thorough, try and make sense of everything. Read and ask questions as you go, shortcuts/patterns will develop over time.
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The Dreyfus model of skill acquisition
1. Novice
2. Advanced beginner
3. Competent
4. Proficient
5. Expert
6. (Master) Dreyfus and Dreyfus (1982)
Benner (1982)
Dreyfus, S (2004) The Five Stage Model of
Adult Skill Acquisition. Bulletin of Science,
Technology & Society 24(3) 177-181 43
1. Novice
• Use rules
• Rules are free of context• E.g. driving (distance behind car in front)
• E.g oxygen saturation
• Lack judgement
• Cannot trouble shoot
• Need to concentrate
• Initial rules allow for accumulation of experience.
• Rules will eventually need to be put aside/adjusted to proceed
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Teaching tip
• Beginners need rules
• Explain the reason behind the rule
• Make sure exceptions to rules are defined as such
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5. Expertise
• When things are proceeding normally, experts don’t solve problems and don’t make decisions, they do what normally works
• Intuition
• Cannot readily articulate why they do what they do
• Totally involved
• High level of situation awareness
• E.g. – conversation, walking, raising children, reading
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“Expert nurses will sometimes sense that a
patient lies in danger of an imminent relapse
and urge remedial action upon a doctor. They
cannot always provide convincing, rational
explanations of their intuition, but very
frequently they turn out to be correct”
Dreyfus (1982)
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“Intuitive grasp should not be confused with
mysticism since it is available only in situations
where a deep background understanding of the
situation exists.”
Benner (1984)
“Intuition is nothing more and nothing less than
recognition.”H. Simon (Nobel Laureate)
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6. Master
• Excels with challenge and surprise
• e.g. Magnus Carlson
• e.g. Miles Davis
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Master: Magnus Carlson
• “Carlson famously trusts his intuition. He may take 30 minutes to make a move but,…” I usually know what I am going to do after about 10 seconds; the rest is double checking. Often I cannot explain a certain move, only I know that it feels right, and it seems that my intuition is right more often than not”.
• All The Right Moves, The Age Good Weekend Magazine March 5 2014
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Master: Miles Davis
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Differences between novices and experts
• Pattern recognition
• Chunking
• Automaticity
• Neuroanatomical changes
• Physiologic changes (for physical skills)
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Recall after 5 sec. exposure
<1650 1650-2000 2000-2350 >2350
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10,000 hours
• Based on work by Anders Ericsson
• Violinists, chess players, at the “elite” level.
• Needs to be 10,000 hours of deliberate practice
“ten years of living in a cave does not make a geologist” (Ericsson)
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*
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Deliberate Practice
• Is challenging
• Requires self discipline
• Requires concentration
• Requires Determination / Motivation
• Is dependant on feedback
• Greatly aided by a coach / teacher
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Vygotsky’s zone of proximal development
Can do
independently
Cannot do even with help
ZPD
Can do with help
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Vygotsky’s zone of proximal development
Can do
independently
Cannot do even with help
ZPD
Can do with help
Too hard / anxiety zone
Too easy/Comfort zone
Just right / learning zone
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Novice to expert
• Can’t skip stages• A novice can imitate an expert but will make mistakes
• Not everyone progresses to be an expert
• People progress at different rates
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Challenges for teaching and learning clinical reasoning• Reasoning cannot be observed
• Experts cannot readily explain how they do it
• Discipline specific
• Content knowledge is required
• Experts do it differently to novices
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The ha ha wall analogy
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How do learners progress?
• Experience is essential – need to see lots of cases
(but experience alone doesn’t guarantee expertise)
• Learners must:• Reflect on experience
• Learn from the experience
• Get feedback
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How can you find the right pitch in your teaching?
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Adaptive expertise
Implications for clinical teachers
• Think about your own clinical reasoning
• Learners must have real world experiences
• Facilitate learning from experience• Help sharpen perceptual skills
• Reflection, thinking, planning
• Provide feedback for students
• Help learners develop rules and recognise patterns, encourage them to make links to similar situations, compare and contrast
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Implications for clinical teachers cont…
• Students need broad experience
• break things down – e.g. sick child
• Content must be learner-centred - an expert can’t predict where the novice is at
• Encourage reflection on experience
• Make your own reasoning explicit
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Take home points
• Clinical reasoning is complex - humans don’t think like machines
• Both analytic and non-analytic processes are used
• Experience is vital for learning, but experience alone doesn’t create expertise• We need to encourage reflective practice
• You can’t teach novice students to think like you (assuming you are expert), but you can facilitate the learning process
• Expertise doesn’t guarantee infallibility
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Further Reading
• Patricia Benner
• Dreyfus & Dreyfus
• Pat Croskerry
• Geoff Norman
• Jerome Groopman
• Anders Ericsson
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‘The art of medicine is to be learned only
by experience: it cannot be revealed.
Learn to see, learn to hear, learn to feel,
learn to smell, and know that by practice
alone can you become expert’
Osler, 1919
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