educator development program school of medicine vanderbilt creating a community of expert thinkers...

Educator Development Program School of Medicine

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Creating a Community of Expert Creating a Community of Expert Thinkers and LearnersThinkers and Learners

A toolkit for medical educatorsA toolkit for medical educators

Creating a Community of Expert Creating a Community of Expert Thinkers and LearnersThinkers and Learners

A toolkit for medical educatorsA toolkit for medical educators

Amy Fleming, M.D.


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IntroductionsIntroductions

• Amy Fleming

• Introduction of Participants


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Conflict of InterestConflict of Interest

• Amy E. Fleming, M.D. has NO financial relationships to disclose.


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GoalsGoals

• To provide an introduction to core concepts in critical thinking

• To explore strategies for active teaching of critical thinking in the preclinical and clinical years

• To build an educator’s tool kit for teaching critical thinking skills


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ObjectivesObjectives

During the session participants will:• Explore core concepts in critical thinking• Examine strategies for teaching critical

thinking• Will develop commitment sheet:

– Teaching plan for your own practice– How to share information with their own faculty.


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Expert ThinkersExpert Thinkers

• Desired outcome of Medical education– Excel at “critical thinking”


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Expert ThinkersExpert Thinkers


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Year two curriculum Marshall University SOM

Year two curriculum Marshall University SOM

• In Year Two, students continue their integration of basic science with clinical medicine in a systems-based curriculum. Students have seven courses which include Approach to Patient Care, Immunology, Microbiology, Advanced Clinical Skills, Pharmacology, Pathology, and Psychopathology. The teaching blocks include Core Concepts, Infectious Organisms and Antimicrobials, Introduction to Neoplasia and Hematology, Nervous System, Cardiovascular System, Pulmonary & Ear, Nose and Throat, Gastrointestinal System, Endocrine and Renal Systems, Musculoskeletal and Genitourinary Systems, and Dermatology, Eye and Toxicology. The curriculum is designed to teach life-long learning and critical thinking skills as students build upon their differential diagnoses with each subsequent block. The Approach to Patient Care course focuses on tying together the instruction from the basic science courses into clinical vignettes, illustrating the challenges and depth of patient care. Through this instruction, the students are prepared to transition more effectively into their clinical years.


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Student Research at MUSOMStudent Research at MUSOM

• Research will strengthen your critical thinking skills and fortify your understanding of the basic science concepts. It will ultimately broaden your perspective from bench to bedside.


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What is Critical Thinking?What is Critical Thinking?


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What is Critical Thinking?What is Critical Thinking?

• “The intellectually disciplined process of actively and skillfully conceptualizing, applying, synthesizing, and/or evaluating information…” -Scriven and Paul, 2010

• “concerned with reason, intellectual honesty, and open-mindedness as opposed to emotionalism, intellectual laziness, and close-mindedness.” -Kurland, 1995


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Critical ThinkingCritical Thinking

Evaluating information

Evaluating our own thought

In a disciplined way.


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Our brand of Critical thinking:Clinical Reasoning

Our brand of Critical thinking:Clinical Reasoning

Clinical Pathophysiology Made Ridiculously SimpleAaron Berkowitz


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Krupat Medical Teacher 2011Krupat Medical Teacher 2011

Critical Thinking:• A Process: of synthesis and analysis• A skill or ability • Characteristics of the individual, personality

traits, habits of mind: (careful attention, curiosity, courage, thinking deeply/openly, awareness of self and others)


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Krupat Medical Teacher 2011Krupat Medical Teacher 2011

• Engage in data gathering: – H&P, go to literature, order tests, consult with experts

• Integrate, organize, synthesize, utilize information: – define and explore all causes, weigh risks/benefits, prioritize

• Communicate with Patients:– Show respect, inform and involve patients

• Make Decisions and Take action: – use best available evidence, ensure information is complete, make plans for

follow up

• Act in ways that are self-reflective: – recognize uncertainties, doubts, limits of knowledge, biases. Understand that

one might be wrong.


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Perkins: conceptual frameworkGood Thinking

Perkins: conceptual frameworkGood Thinking

• Sensitivity: awareness of flow of events, need for more information, value of understanding alternatives

• Inclination: committed to invest the effort in thinking the matter through

• Ability: knowledge, skills, how to frame questions, integrate information, apply one’s knowledge


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What is Critical thinking?What is Critical thinking?

• How can we foster a climate throughout our university that is focused on the development of thinking abilities?

• “Critical thinking is not something to be devoured in a single sitting nor yet in a couple of workshops. It is to be savored and reflected upon. It is something to live and grow with, over years, over a lifetime.”

• a teachable cognitive skill independent of specific knowledge


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How did you learn critical thinking?

How did you learn critical thinking?

www.media.photobucket.com


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How did you Learn Critical Thinking?

How did you Learn Critical Thinking?

• Often not “taught”• Practice, experience• Unconscious learning• Talking out loud• By being challenged with questions… why?

What are you thinking?• Expert modeling


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4 Stages of Competence4 Stages of Competence• Unconscious Incompetence

– Do not recognize the deficit – Neither understand nor know how to do something

• Conscious Incompetence– Realize you don’t know

• Conscious Competence– Understand/know how to do something, but demonstrating the

skill/knowledge requires concentration/consciousness

• Unconscious Competence– Second nature, like riding a bike – Hard to teach/break down this automatic thinking

1940's psychologist: Abraham Maslow


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5th Stage of Competence5th Stage of Competence

If unconscious competence is the top level, then how on earth can I teach critical thinking?

• Reflective competence -David Baume, May 2004

• Conscious competence of unconscious competence

• Superconscious Meta-competence– Move beyond thinking intuitively and are able to teach in a very

deliberate way– Person's ability to recognize and develop unconscious competence in

others


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Stages of CompetenceStages of Competence

Courtesy of Will Taylor, Chair, Department of Homeopathic Medicine, National College of Natural Medicine, Portland, Oregon, USA, March 2007


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BUT…BUT…

by Sidney Harris


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Tool Kit:Tool Kit:

• Priming and Framing• Learning Script• Active Observation• One Minute Preceptor• SNAPPS• Illness Scripts


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PrimingPriming

• Provide patient-specific information before learner enters the room– “4-year old boy with global developmental delay, a

congenital heart defect, and respiratory distress.”

• Prepare the learner for the encounter by asking case-based questions– What should you ask to understand the respiratory

distress? – What will you ask regarding the congenital heart defect

history?


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FramingFraming

• Tell the learner what should be accomplished during the visit and how long it should take

• “This child has a history of global developmental delay and congenital

heart disease but is being admitted for respiratory distress. Focus on the

evaluation for the respiratory distress acutely. Make sure to cover his

history of heart disease as it pertains to his acute presentation. Don’t

dwell on the developmental history. Spend about 30-45 minutes on the H

and P, then come find me.”


VANDERBILTPriming


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Priming and FramingPriming and Framing

• Shadowing

• Standardized Patients:

– Hypothesis-Driven Physical Exam

• (1) orientation, (2) anticipation, (3) preparation, (4) role play, (5)

discussion-1, (6) answers, (7) discussion-2, (8) demonstration and (9)

reflection. Nishigori, Bordage, et al: Medical Teacher, Feb 2011.

Eva, Bordage, et al: Med Educ. Aug 2010.

• Independent Learners

– Quick search on chief complaint


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Priming and FramingPriming and Framing

• Priming: Comprehensive knowledge of the gross and microscopic structure of the human body to provide an anatomical basis for disease presentations.

• Framing: To introduce CT scans, and the interpretation of anatomy as visualized by this technique.


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Learning ScriptLearning Script• Works best when a presentation is involved.

• After participating in activity (histology lab, on call autopsy, case discussion, oral presentation on rounds) learner writes 2-3 things that s/he wants to learn on an index card

• Learner gives card to teacher and then presents

• During presentation, teacher can address issues or questions on card or they can wait until later.

• At completion of case, return card to learner

• Learner picks 1 or 2 issues to research. Follow up next time!


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Learning ScriptLearning Script• Learner centered• Teacher doesn’t have to anticipate learner

needs• Expectation that learner will have questions• Emphasizes curiosity, questioning, learner

motivation• Allows teaching at multiple levels


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Active ObservationActive Observation

• Can be used for learners with little to no medical training, such as undergraduates

• Can be used in large case settings, lectures, clinical shadowing, critical situations (codes)

• Explain rationale for focused observation (medical anthropologist)


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Active ObservationActive Observation• Tell learner what to observe:

– 3 columns on 3x5 card– See - Reaction - Why– Review what is written on card after the experience– Learner can also write questions on the card

• Give feedback on observations• Excellent mechanism for teaching at the level of the

learner • Allows teaching on “attitudes”, professionalism,

communication


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Active ObservationActive Observation

See

The mother was angry and raised her voice when we walked into the room.

You (the attending) sat down

Reaction

Uncomfortable

I wanted to leave

Why

Why was the mother mad?

Why did you sit down?


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Active Observation: colloquiumActive Observation: colloquium

See

We were watching the movie “The Elephant Man.” During a scene where the doctors were displaying the elephant man in front of the entire lecture hall several students giggled.

Reaction

I was very unhappy with the student responses.

My reaction was that this was an unprofessional response

Why

Why did people laugh at this awful doctor patient interaction?


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One Minute PreceptorOne Minute Preceptor• Learner has presented encounter with patient

• Get a commitment from learner – “What do you think is going on?”

• Probe for supporting evidence (reasoning)– “What led you to that conclusion?”– “Did you consider alternatives?”


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One Minute PreceptorOne Minute Preceptor• Reinforce what was done well

– “Your diagnosis of X was well supported by Y”

• Identify omissions or correct errors– “Although your suggestion is possible, in a situation like

this I think that Z is more likely because…”

• Teach general principles and next learning steps– Help learner build foundations and structure for future

questions.


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SNAPPSSNAPPS

Learner-centered model in which the learner:– SUMMARIZES briefly the history and findings– NARROWS the differential to 2-3 possibilities– ANALYZES the differential by comparing and contrasting the

possibilities– PROBES the preceptor by asking questions about

uncertainties, difficulties, or alternative approaches– PLANS management for the patient– SELECTS a case-related issue for self-directed learning

Wolpaw


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Illness ScriptsIllness Scripts

• Breaking down the way physicians approach clinical reasoning to a very basic level.

• The patient who “read the book.”


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Practice Problem RepresentationPractice Problem Representation

• 18yo woman


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• 18yo woman• Admitted for acute abdominal pain.


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• 18yo woman• Admitted for acute abdominal pain.• Has associated anorexia


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• 18yo woman• Admitted for acute abdominal pain.• Has associated anorexia• Initial pain peri-umbilical, now localized in RLQ


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• 18yo woman• Admitted for acute abdominal pain.• Has associated anorexia• Initial pain peri-umbilical, now localized in RLQ• Has rebound tenderness and pain over

McBurney’s point


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Illness ScriptIllness Script

• 8yo boy


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• 8yo boy• Admitted for acute abdominal pain and poor PO

intake.


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intake.• Has a purpuric rash in a waist-down distribution.


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intake.• Has a purpuric rash in a waist-down distribution.• Presents with proteinuria and large joint pain.


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intake.• Has a purpuric rash in a waist-down distribution.• Presents with proteinuria and large joint pain.

»Henoch Schonlein Purpura


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Physician ReasoningPhysician Reasoning

• Physicians essentially use 2 modes of thinking:

– Pattern Recognition:• Clinician has seen the problem before• Fast (<10 sec), automatic, largely accurate

– Analytical Thinking: • Clinician is puzzled or can’t find the pattern• Slower and more conscious process

Norman et al (1989 and 1992)


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• Expert clinicians store and recall knowledge as diseases, conditions or syndromes – “illness scripts” – that are connected to problem representations

• These representations trigger clinical memory permitting the related knowledge to become accessible for reasoning

• Knowledge recalled as illness scripts has a predictable structure: – The predisposing conditions– The pathophysiological insult– The clinical consequences

Judith Bowen, NEJM 2006


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Resident (expert) vs Medical student (novice) Resident (expert) vs Medical student (novice)– Expert: has seen similar case before

• Forms an early impression (mental abstraction) of the patient’s story• Asks a series of guided questions and performs a focused exam• Searches for information that can be used to discriminate among

different diagnostic explanations• Gives a succinct presentation, transforms the patient’s story into a

meaningful clinical problem

– Novice: has never seen case before• Asks a broad range of questions and performs an extensive exam• Try to solve the problem without building a problem representation

(too close to the details to see the big picture)• Students are better at interpreting available findings than selecting

useful ones. Judith Bowen NEJM 2006


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Illness ScriptsIllness Scripts• Enter with multiple

hypotheses– Discriminating features

• Gather additional data• Problem Representation

– Synthesize into the big picture (one liner)

• Select Illness Script for working diagnosis

• Verify working diagnosis

Judith Bowen NEJM 2006


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Problem RepresentationProblem Representation

• Summarizes the specific case in abstract terms• Uses semantic qualifiers

– Paired, opposing descriptions that can be used to compare and contrast diagnoses

• Last night acute• Right knee single large joint

• Links stored knowledge with the current clinical case

• Bowen NEJM 2006, Bordage Acad Med 1999


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Appendicitis CaseAppendicitis CaseProblem representation for our patient

• 18yo woman• Admitted for acute abdominal pain.• Has associated anorexia• Initial pain peri-umbilical, now localized in RLQ• Has rebound tenderness and pain over McBurney’s

point


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Appendicitis CaseAppendicitis Case

• Caitlyn is an otherwise healthy 18yo who presents with acute, severe, localized RLQ abdominal pain, anorexia, and nausea, with an exam concerning for acute abdomen.


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Clinical consequences – Distinguishing features & progression of the disease?

Semantic (Abstract) Qualifiers

Cognitive Biases (Diagnostic Pause)

-Anchoring bias

-Confirmation bias

-Premature diagnosis closure

-Availability bias

-Representativeness bias

Bordage G, Acad Med 1999

Bowen JL. NEJM 2006

T.J. Jirasevijinda


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Acute

1st presentation

Mild

Diffuse

Non-surgical abdomen

Chronic

Recurrent

Severe

Localized

Acute Abdomen


-Anchoring bias

-Confirmation bias


-Availability bias



Bowen JL. NEJM 2006

T.J. Jirasevijinda


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Severe acute abdominal pain periumbilical moving to McBurney’s point Nausea, Vomiting, Anorexia Fever, possible sepsis Peritoneal signs, Surgical abdomen


Acute

1st presentation

Mild

Diffuse

Non-surgical abdomen

Chronic

Recurrent

Severe

Localized

Acute Abdomen


-Anchoring bias

-Confirmation bias


-Availability bias



Bowen JL. NEJM 2006

T.J.


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Attending ExampleAttending Example


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Verify the DiagnosisVerify the Diagnosis

• Does the diagnosis make sense?• Does the diagnosis explain all the H&P findings?• What features remain confusing?• Do I need to acquire more data?


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Modified from Judith Bowen 2006

Diagnostic Pause

Diagnosis


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Cognitive Bias PitfallsCognitive Bias Pitfalls

• Availability Bias: the diagnosis is easily recalled; depends on frequency of what you have seen in the past (Non-availability bias: out of site, out of mind…)

• Representativeness Bias: it looks like a duck, walks like a duck, so it is a duck

• Anchoring Bias: too much reliance on one piece of information / data

• Confirmation Bias: seek info to confirm your initial impression, weigh evidence favoring diagnosis more heavily

• Premature Diagnostic Closure: reaching a diagnosis and failing to assimilate additional information that contradicts it

Croskerry 2002, Bordage 1999


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Teaching this to OthersTeaching this to Others

• General principles of effective faculty development activities:–Participants should identify a learning gap ahead of

time.–Sessions that are interactive + didactic are more

effective than either alone.-Consider having faculty work in groups, as opposed

to individuals.from O’Sullivan and Irby, Reframing Research on Faculty

Development, Academic Medicine, April 2011


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Teaching this to OthersTeaching this to Others

• Principles of effective faculty development:- Faculty should commit to a behavior change before

leaving. - They should plan to do PDSA cycles on this behavior

change - They should leave with a plan to measure their efficacy

(consider accountability or check-ins)

- from O’Sullivan and Irby, Academic Medicine, April 2011


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Make a Personal PlanMake a Personal Plan

• Write down one or two tools you will try in your practice in the next month– Which tool will you try?– Why did you choose this tool?– How will you utilize it?– What challenges do you anticipate to using it?– How will you measure its success/failure?


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Tool Kit:Tool Kit:

• Priming and Framing• Learning Script• Active Observation• One Minute Preceptor• SNAPPS• Illness Scripts


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Summary of GoalsSummary of Goals

• To provide an introduction to core concepts in clinical reasoning

• To explore strategies for active teaching of clinical reasoning in the clinic and at the bedside

• To build an educator’s tool kit for teaching and evaluating their student’s clinical reasoning skills


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Review of workshop objectivesReview of workshop objectives

During the session participants will:• Explore core concepts in clinical reasoning• Apply strategies for teaching clinical reasoning• Analyze students’ clinical reasoning skills in

oral presentations


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• "Education would be much more effective if its purpose was to ensure that by the time they leave school every boy and girl should know how much they do not know, and be imbued with a lifelong desire to know it."

– William Haley, British Editor

educator development program school of medicine vanderbilt creating a community of expert thinkers...

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critical thinking slide

clinical medicine

critical thinking skills

term critical thinking

core concepts

clinical years

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basic science concepts