teaching clinical reasoning in the apprenticeship model
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THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Teaching Clinical Reasoning In The
Apprenticeship Model
Nothing
My Thanks Dennis Baker Greg Turner Lynn Romrell
Goals* Stimulate discussion of clinical
reasoning in the context of curriculum redesign
* Share ideas with those who design and implement the 3rd and 4th years of our medical education program.
Objectives1. Describe the role of analytical reasoning
and pattern recognition in clinical decision making.
2. Define cognitive bias and give examples of the mental errors resulting from it.
3. Define framing and give examples of how a physician’s framing of information can lead to an uniformed patient decision
4. Describe strategies the clinical teacher can use to facilitate the learner’s acquisition of clinical reasoning skills
What opportunities do we have?
Consistent with the U.S. national failure pattern, 10% of our 2nd year students in the past 2 years have failed USMLE step 1.
Additional students have trouble with the first or second NBME shelf exams in the third year.
Many of them struggle with OSCE cases that they represent a “mystery” diagnosis.
Even Among Practicing Physicians
Misdiagnosis is common: 15-20% Most of the time (80%) these are
cognitive errors, not knowledge deficits
“Thinking about our thinking as physicians”Jerome Groopman, MD, FACP, and Pamela Hartzband, MD, FACP
What Are We Doing Currently?
CurrMIT data: Clinical reasoning was coded as a
topic in 389 session (lectures, labs, small groups, etc.)
We do not know the amount of time spent on the topic or even if it was a major point of emphasis. We just know the topic was covered.
COURSE SESSIONS
Clinical Anatomy/Embryology/Imaging 36Clinical Microanatomy 17Clinical Neuroscience 34Clinical Physiology 21Doctoring 101 14Doctoring 102 14Doctoring 103 21Doctoring 201 32Doctoring 202 36Doctoring 3 49Health Issues in Medicine 201 1Medical Biochemistry and Genetics 9Medicine and Behavior 201 8Medicine and Behavior 202 4Microbiology 201 11Microbiology 202 11Pathology 201 16Pathology 202 20Pharmacology 201 10Pharmacology 202 25Grand Total 389
How well are our students doing?
To Students You Are a Wizard
How can we help students develop their clinical reasoning skills?
For the Expert ……………
(Benamy, 1996)
For the Learner ………A Developmental Competency
Experience and Deliberate Practice
Deliberate PracticeDoing something wrong repeatedly will not improve the outcome.
Clinical Reasoning DefinitionThe process by which clinicians collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the experience.Hoffman, 2007; Kraischsk & Anthony, 2001; Laurie et al., 2001
Diagnosis Hypothesis generation Context formulation Test interpretation Bayesian reasoning Causal reasoning Differential diagnosis Assessing for adequacy Working diagnosis Cognitive Errors
Clinical Reasoning ConceptsTreatment
Treatment under uncertainty
Risk benefit analysis Treatment thresholds “Toss ups” Therapeutic trial Watchful Waiting
Cognitive Approach To Clinical Reasoning
Analytical (Deliberate) Novice: Does Not Recognize the Pattern Expert: Case Does not Fit the Pattern
Non-Analytical (Pattern Recognition, Intuitive)
Analysis: A Deliberate Approach Principles of logic and hypothesis
testing. Journal Club Start with what we know. Problem solving algorithms.
Head to Toe, Body Systems, Pathophysiology, Acute vs Chronic, Rule out Worst Case Scenario, Exhaustive method, Deductive (Covered in Doctoring 103)Acad Emerg Med: November 2002, Vol 9, No.11
Curriculum for First Two YearsYEAR 1
Doctoring 1 Anatomy Neuroscience Physiology Biochemistry and
Genetics
YEAR 2 Doctoring 2 Microbiology Pharmacology
Pathology Medicine and
Behavior
Constructing a Differential For Syncope
Consciousness requires: Glucose Oxygen Adequate BP and blood flow to
deliver above Organized electrical activity in the
brain Syncope results when any of these
are impaired
Probability Bayesian Theory The predictive value of any
diagnostic test is proportional to the prevalence of the disease in the population tested.
Describes uncertainty when potential outcomes are not equally likely.
As evidence is collected the probability is altered.
About 1 out of every 5,000 people in the US has Marfan Syndrome.
Degree of Certainty Physicians often need to make
decisions with incomplete information
We can always do “one more test.”Odds vs. Stakes (Chest Pain, Rectal
Bleed)Cost vs. Benefit (Unexplained Wt
Loss)Defensive Medicine
Non-Analytical Reasoning
Pattern Recognition Teaching Points
Make the Pattern Fit the Patient, not the Patient Fit the Pattern. (18 month old with lethargy and hyperglycemia)
Don’t stop looking until it fits. Reconcile symptoms (palpitations,
lightheadedness) with findings (EKG, blood glucose)
Avoiding Cognitive Land Mines
Beware! Decisions are not simply a result of logic.
Cognitive Bias Our attempt to Simplify Complexity Simple rules of thumb that lead to
predictably faulty judgments Subconscious mental procedures for
processing information Remains compelling even after one is
aware of itCenter for the Study of Intelligence, CIA, 1999
Examples Aggregate bias Anchoring Ascertainment bias Availability Confirmation bias Fundamental Attribution error
Gambler’s fallacy
Gender bias Hindsight bias
Illusory Omission bias Outcome bias Overconfidence
bias Playing the odds Premature Closure
Representativeness Restraint Visceral bias Zebra retreatAchieving Quality in Clinical Decision Making: Cognitive Strategies and
Detection of Bias by Pat Croskerry, MD, PhD
Overconfidence BiasA willingness to diagnose based on incomplete information when relevant information is available.
Confirmation Bias
The tendency to seek out and assign more significance to evidence that confirms a pattern and ignore or assign much less significance to evidence that does not.
Friendly Fire1994 Iraq No Fly Zone‾ Air Force F-15s‾ Air Force AWAC Plane‾ Army Blackhawk
Helicopters
Snook, Scott A. Friendly Fire: The Accidental Shootdown of U.S. Black Hawks Over Northern Iraq. Princeton, NJ: Princeton University Press, 2000. (Winner of the George R. Terry Book Award, Academy of Management, 2002.)
Army Black Hawk Hind
They saw what they expected
A Patient with Chest Pain
68 year-old male with known coronary artery disease presents with chest pain, nausea and shortness of breath and a complaint of “I’m having another heart attack doc.”
Anchoring Tendency to rely too heavily on one
piece of information when making decisions.
OR Inappropriate reference point
Illusory Bias Causation Association Background Noise
Breast Implant Law Law Offices of Stephen M. Frailich
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• Hair loss
• Swelling • Memory Loss
Atypical Connective Tissue Disease
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More Associations Silver Dollars and Umbilical Hernias Antibiotics and viral infections Bed Rest and Premature Labor
A Really Bad Duo Unavoidable Risk Information Cascade
Cognitive Bias Teaching Points
Confirmation: Does everything fit? Illusory: What is the real
relationship? Overconfidence:
Did you find everything? Anchoring, Availability, Attribution:
What else could it be?
Framing Mental model that influences how we
present an issue to others. Influence of risk-aversion on decision
making.
Opportunity or Threat?
Relative or Absolute Risk
Chantix for Smoking Cessation Chantix Representative Long Term (1 year) quit rate with
Chantix is 270% that of placebo Welbutrin Representative
Rate of serious Cardiovascular Events with Chantix was 25% higher than placebo
The Medical Letter on Drugs and Therapeutics • August 22, 2011 (Issue 1371) p.65
Metacognition A method of introspection in which
one is expected to contemplate or reflect on their own thinking to avoid cognitive errors.
A check and balance between intuition and analysis.
Important Points Disease is a movie, you may only
have one scene. Defensive Medicine is not Clinical
Reasoning. How we think, is what we will teach. Let the students hear you
“think out loud”.
Role of Clinical Faculty“The role of the teacher is not to transmit knowledge but to facilitate learning, encourage spontaneity, and engage in mutual inquiry.”“The best time to learn anything is when the material is immediately useful.”“Deliberate Practice”Teaching Clinical Reasoning: Case-Based and Coached Jerome P. Kassirer, MD
Ideal Learning Environment
Multiple Patient Exposures Beginning in the First Year Deliberate Developmental
Progression Learner Driven Expert Mentors
Should we further develop a clinical reasoning curriculum?
What would the developmental progression look like?
Would the Doctoring courses form the backbone?
How do we train/engage the clinical faculty?
Some Questions
References “How Doctors Think”
Jerome Groopman Lecture Series – The Art Of Critical Decision Making
Professor Michael Roberto Lecture Series - What Are the Chances? Probability Made Clear
Michael Starbird, Ph.D. “Thinking about our thinking as physicians” ACP Internist and American College of Physicians, October 2011 Jerome Groopman, MD, FACP and Pamela Hartzband, MD, FACP Wikipedia Google Images
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