UCSF Educational Skills Workshop Educational Strategies to Promote

UCSF Educational Skills Workshop Educational Strategies to Promote Clinical Reasoning Gurpreet Dhaliwal MD

Workbook & skills assessment are @. . http: //tiny. ucsf. edu/Clin. Reas 2

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Educational Strategies to Promote Clinical Reasoning Gurpreet Dhaliwal MD 4

Any data… History Exam Labs Imaging ? Diagnosis 5

Diagnosis ? Treatment 6

Da ta Ga ic t s no the r ed y c a r u c Ac g a i D Student Attending 7

Goals • How do you analyze clinical reasoning? [Dx] • How do you improve it? [Rx] Moving past… – Dx = ↓ fund of knowledge – Rx = see more, read more 8

Pre-Test

“ 24 year old man with acute fever and cough” is an example of … a) Illness script b) Schema c) Problem Representation 10

“ 24 year old man with acute fever and cough” is an example of … a) Illness script b) Schema c) Problem Representation 11

An ILLNESS SCRIPT is… a) b) c) Constructed by the learner Delivered by the teacher Varies from patient to patient 12

An ILLNESS SCRIPT is… a) b) c) Constructed by the learner Delivered by the teacher Varies from patient to patient 13

You can identify a competent reasoner because she articulates… a) b) c) The latest evidence A persuasive argument How to exclude the worst case scenario 14

You can identify a competent reasoner because she articulates… a) b) c) The latest evidence A persuasive argument How to exclude the worst case scenario 15

Dx 16

Dx 17

Problem Representation Schema Illness Scripts Dx Prioritized differential diagnosis 18

Content [edit] 1. Clinical Features a. History b. Physical c. Labs/Imaging 2. Epidemiology 3. Pathophysiology 4. Treatment 5. Illness Course 19

Content [edit] 1. Clinical Features a. History b. Physical c. Labs/Imaging 2. Epidemiology 3. Pathophysiology 4. Treatment 5. Illness Course 20

Problem Representation Schema Illness Scripts Dx Prioritized differential diagnosis 21

Problem Representation I have pain “under my right rib” “after I eat” “on and off” “for the last 2 days” “really hurts” Subacute intermittent severe post-prandial RUQ pain. 22

Problem Representation 1. Who is this patient? • • Demographics PMH 2. What is the syndrome? • Key features 3. What is time course? • • Duration Tempo Ø 32 y/o healthy man Ø severe, post-prandial RUQ pain Ø subacute, intermittent 23

Subacute intermittent severe post-prandial RUQ pain 24

Name Edit the problem 19 year old woman is brought to the emergency department… 25

Name Edit the problem 1) 2) 3) 4) 5) 6) 7) Open your workbook @ http: //tiny. ucsf. edu/Clin. Reas Case 1 is on page 1 @ 0: 00 -2: 00 – read the case independently @ 2: 00 – enter your breakout room (4 per room) 2: 00 -5: 00 discuss how you would revise the problem representation; elect 1 person to type the revised PR into the chat (later) @ 5: 00 – exit the breakout room After you exit the breakroom, 1 person per group types a revised PR into the chat 26

• 19 y/o woman w/ acute fever and headache. 27

• 19 y/o woman w/ acute fever and headache. • 19 y/o woman w/ fever, headache, and unresponsiveness. • Young healthy woman with URI followed by fever, headache, AMS, and tachycardia. • College student with fever, headache, and neck pain/stiffness. 28

Problem Representation Schema Illness Scripts Dx Prioritized differential diagnosis 29

Schema 30

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The Schema The Problem Illness Scripts 32

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1) 2) 3) 4) 5) 6) @ 0: 00 -1: 00 -- Think of a problem you commonly teach about It must be a problem, not a disease - knee pain, not gout @ 1: 00 -4: 00 Draw out a schema on a sheet of paper Start with the problem at the top It’s a schema that you would share with a leaner @ 4: 00 – Share your schema with group When the time for viewing/sharing schemas comes, click “Speaker view” in upper right hand corner of Zoom screen. 35

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Problem Representation Schema Illness Scripts Dx Prioritized differential diagnosis 37

Hypoxia JVP ↑ WBC ↑ Fever Edema Infiltrates Cough 38

Hypoxia JVP ↑ WBC ↑ Fever Edema Infiltrates Cough 39

Hypoxia JVP ↑ WBC ↑ Fever Edema Infiltrates Cough 40

Prioritized Differential Diagnosis (a diagnostic argument) “ 64 man with subacute progressive dyspnea, hypoxemia, and bilateral infiltrates. ” I. Most Likely II. Less Likely III. Unlikely ++++/++/-+/--41

Prioritized Differential Diagnosis (a diagnostic argument) “ 64 man with subacute progressive dyspnea, hypoxemia, and bilateral infiltrates. ” I. Most Likely: CHF II. Less Likely: PNA III. Unlikely: ILD JVP, crackles, edema but … low BNP cough, infiltrate but … no fever, no WBC all compatible but … time frame 42

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Your Next Teaching Encounter 44

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Am I Teaching Clinical Reasoning? Synonym Problem Representation Schema Illness Script Prioritized DDx Summary statement One liner Framework Approach Algorithm Knowledge Experience Compare & contrast “Put your nickel down” “Tell me what you think it is” 46

Am I Teaching Clinical Reasoning? Novice Model Intermediate Advanced Practice Analyze Problem Representation Schema Illness Script Prioritized DDx 47

“Give me a summary statement” “How do you categorize the causes of arthritis? ” “What about this case is consistent with gout? ” Dx “What is your prioritized ddx for this case? ” 48

1. His/her problem representation is … 2. His schema is… 3. His illness scripts are… 4. His prioritized ddx skills are… My educational strategy is to …. 49

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Case 2: Knee pain • Gut: good. On the right track. “In summary, he is a healthy man with fever and the acute onset of a 1. Problem representation: good 2. Schema: can’t tell single sustained episode of severe pain and swelling in the left knee, more in the front of the joint. I 3. Illness Script: strong / weak know it is unusual to have intact 4. Prioritized DDx: can’t tell I’m not really sure what it is. ” range of motion in septic joint, so 51

Am I Teaching Clinical Reasoning? Novice Model Intermediate Advanced Practice Analyze Problem Representation Schema Illness Script X X Prioritized DDx 52

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Case 3 54

Case 3 1) 2) 3) 4) 5) 6) 7) Open your workbook @ http: //tiny. ucsf. edu/Clin. Reas Case 3 is on page 3 @ 0: 00 -2: 00 – read the case independently @ 2: 00 – enter your breakout room (4 per room) 2: 00 -5: 00 how you would assess the reasoning here – how is the resident’s schema, scripts, and prioritization for treatment options? @ 5: 00 – exit the breakout room After you exit the breakroom, we will invite verbal reports re: the educational dx and rx for this learner 55

What is clinical reasoning? It’s solving a problem. 1. 2. 3. 4. Collect information Define the problem Search for solutions Pick best solution 56

Persuasive Argument - Rx For this given Dx, in this given patient, … Preferred Acceptable Imprudent ++++ / -+ / --57

Rx schema Cholecystitis (inflamed gallbladder) Surgical Cholecystostomy (Interventional Radiology) Medical Cholecystectomy (Surgeon) Antibiotics (Hospitalist or surgeon)

Case 3: Rx Reasoning • Gut: work in progress. 1. Problem representation: OK = the known Dx of cholecystitis 2. (Rx) Schema: not developed yet 3. (Rx) Script contents: hard to tell 4. Prioritized (Rx) differential: hard to tell 59

Am I Teaching Clinical Reasoning? Novice Model Intermediate Advanced Practice Analyze Problem Representation Rx Schema Rx Script Prioritized DRx X X X 60

Case 4 36 year old woman with abdominal pain… 61

Prioritized DDx 39 year old woman with 3 days of epigastric pain and tenderness and vomiting I. Likely II. Plausible III. Unlikely Gastroenteritis, pancreatitis, hepatitis Pyelonephritis Cystitis Inflammatory bowel disease Ectopic pregnancy 62

Composition 1. 01: How Email Can Change the Way Professors Teach James Somers The Atlantic 2011 63

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Struggling Competence Excellence Remediation Curriculum Training Regimen 67

“I want this person caring for my family” Performance “Solid resident” Time 68

Skills assessment & Evaluation are @. . http: //tiny. ucsf. edu/Clin. Reas Required for session credit. 69

Am I teaching clinical reasoning? 70

Am I teaching clinical reasoning? Assessment of Learning + Assessment for Learning Data evaluation form 71

Am I teaching clinical reasoning? Assessment of Learning Assessment for Learning + Data evaluation form + Data pointers/general feedback 72

Am I teaching clinical reasoning? Assessment of Learning Assessment for Learning + Data evaluation form + ++ Data pointers/general feedback Data feedback (CR framework) 73

Am I teaching clinical reasoning? Assessment of Learning Assessment for Learning + Data evaluation form + ++ +++ Data pointers/general feedback Data feedback (CR framework) “take it from the top” 74