Teaching Clinical Reasoning In The Apprenticeship Model

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Dennis Baker Greg Turner Lynn Romrell

* * Stimulate discussion of clinical reasoning in the context of curriculum redesign Share ideas with those who design and implement the 3 rd and 4 th years of our medical education program.

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Describe the role of analytical reasoning and pattern recognition in clinical decision making .

Define cognitive bias and give examples of the mental errors resulting from it.

Define framing and give examples of how a physician’s framing of information can lead to an uniformed patient decision Describe strategies the clinical teacher can use to facilitate the learner’s acquisition of clinical reasoning skills

   Consistent with the U.S. national failure pattern, 10% of our 2 nd 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.

  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

 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 Clinical Anatomy/Embryology/Imaging Clinical Microanatomy Clinical Neuroscience Clinical Physiology Doctoring 101 Doctoring 102 Doctoring 103 Doctoring 201 Doctoring 202 Doctoring 3 Health Issues in Medicine 201 Medical Biochemistry and Genetics Medicine and Behavior 201 Medicine and Behavior 202 Microbiology 201 Microbiology 202 Pathology 201 Pathology 202 Pharmacology 201 Pharmacology 202 Grand Total

SESSIONS

36 17 34 21 14 14 21 32 36 49 1 9 8 4 11 11 16 20 10 25 389

How can we help students develop their clinical reasoning skills?

(Benamy, 1996)

A Developmental Competency Experience and Deliberate Practice

Doing something wrong repeatedly will not improve the outcome.

The process by which clinicians collect cues , process the information , an understanding come to of a patient problem or situation, interventions , reflect plan and implement evaluate outcomes , and on and learn from the experience.

Hoffman, 2007; Kraischsk & Anthony, 2001; Laurie et al., 2001

Clinical Reasoning Concepts

         Diagnosis Hypothesis generation Context formulation Test interpretation Bayesian reasoning Causal reasoning Differential diagnosis Assessing for adequacy Working diagnosis Cognitive Errors       Treatment Treatment under uncertainty Risk benefit analysis Treatment thresholds “Toss ups” Therapeutic trial Watchful Waiting

 Analytica l (Deliberate) Novice: Does Not Recognize the Pattern  Expert: Case Does not Fit the Pattern Non-Analytical (Pattern Recognition, Intuitive)

   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

     YEAR 1 Doctoring 1 Anatomy Neuroscience Physiology Biochemistry and Genetics      YEAR 2 Doctoring 2 Microbiology Pharmacology Pathology Medicine and Behavior

  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

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.

  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

   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)

Decisions are not simply a result of logic.

    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 it Center for the Study of Intelligence, CIA, 1999

          Aggregate bias Anchoring Ascertainment bias Availability Confirmation bias Gender bias Hindsight bias  Illusory    Overconfidence bias   Playing the odds Restraint   Omission bias Outcome bias Visceral bias Zebra retreat Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias by Pat Croskerry, MD, PhD

A willingness to diagnose based on incomplete information when relevant information is available.

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.

‾ ‾ ‾ 1994 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

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.”

  Tendency to rely too heavily on one piece of information when making decisions.

OR Inappropriate reference point

   Causation Association Background Noise

Attention Women who have had breast implants and are having health problems.

Do you have the following symptoms?

• • • • • • Chronic Headaches & Fatigue Upper & Lower Back Pain Pain in your Breast Joint Pains Muscle Pains Unexplained Rashes • • • Hair loss Swelling Memory Loss

Dear Mr. Frailich, “Your winning the $110,000.00 Dow Class Action claim for my wife, was a tremendous boost to our morale after my wife's suffering so many years with the symptoms of implant toxicity. We were also surprised to receive the claim check much earlier than your office predicted that we may.” 1/7/11 J.P. Grand Rapids, MI

   Silver Dollars and Umbilical Hernias Antibiotics and viral infections Bed Rest and Premature Labor

  Unavoidable Risk Information Cascade

    Confirmation: Does everything fit? Illusory: What is the real relationship? Overconfidence:

Did you find everything?

Anchoring, Availability, Attribution:

What else could it be?

  Mental model that influences how we present an issue to others.

Influence of risk-aversion on decision making.

Opportunity or Threat?

   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

  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.

    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

”.

“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

     Multiple Patient Exposures Beginning in the First Year Deliberate Developmental Progression Learner Driven Expert Mentors

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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?

      “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

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