Clinical Reasoning

Hypothesis-Driven History-Taking Project

Provide the context & rationale for HDHT project

Situate the HDHT project within clinical education

Explain learning objectives of the ModuleShow module Explain SP exercise assessmentHow to access? When available? SP

exercise?

“Expert clinicians begin to generate hypotheses regarding the suspected illness very quickly while gathering cues and information from the patient.”Pattern recognition

“This hypothesis driven approach is a means of coping with the open-ended problem presented by a patient.”I’m not

sleeping very well…

There could be several explanations…Let me get some more information from you…

‘The function of early hypotheses, therefore, is to limit thesize of the space that must be searched for solutions to

theproblem.’

‘Some way of progressively constraining the sizeof the search space must be found or else a clinicalworkup could never end in the time that is actuallyavailable’

Hypotheses transform an open problem into one with several hypothetical solutions…

The goal of the interview and physical examination is to carry out a comparative evaluation of these competing ‘diagnoses’.

Differential Diagnosis

“This hypothesis driven approach = means of coping with the open-ended problem presented by a patient.”

Creates a Tension !Also a Problem…

Hypothesis Driven Approach Patient Centered Approach

Patient Centered

Astute Diagnostician

Unfortunately,

“Clinical educators insist that students carry

out a history:• Following a formulaic path • Suspending, until the end, speculation on

the illness in question.”

Cardinal Questions▪ Problem?▪ Quality?▪ Duration, time course?▪ Intensity?▪ Aggravating?▪ Alleviating?▪ Radiation?▪ Associated Symptoms?

Unfortunately..

“Clinical educators insist that students carry out a history and a review of systems by following a prescribed path suspending, until the end, all formulations of the illness in question.”

Patient: “What are you thinking?” Physician: “Oh, I haven’t started

thinking yet. First I gather all the information and then I think about it.”

“We detriment our students in the traditional training approach by teaching a scheme that is not actually the one we expect them to utilize a scant year or two later.”

What clinicians would actually admit that such is their method of reasoning!

HPICardinal Question

s:ProblemLocationSeverity

AggravatingAlleviatingRadiatingAssoc Sxs

Cardinal Question

s

Pertinent +/-

Year 1 Year 2 Year 3 Year 4 Normal Pathology Patient Contact Develop Skills

Hypothesis Driven History Module:

Introduce Process

Case Profiles - illness scripts

Enhance diagnostic abilities

Introduce pattern recognition

Maintain Patient-Centeredness

Objectives

Learning Module

SP Exercise Quiz

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Web module: Clinical Reasoning - epistemology

Diagnostic scripts & pattern

Self-Assessment Questions/Answers

Module

-Module Open for Study February 17, 2010

-To Access Module: To be given out at lecture Feb 16th

-SP Encounter & Quiz March 23, 2010 (Entire Class)

Module’s Web link address

Timeline of Activities for Project