Diagnostic Reasoning DR Toolbox for Hospitalist Faculty
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1 Diagnostic Reasoning DR Toolbox for Hospitalist Faculty Heather Hofmann, MD Department of Medicine
2 2
3 Goal Increase faculty familiarity with diagnostic reasoning principles and tools so as to improve its teaching.
4 Three Parts: I: Introduction to Diagnostic Reasoning II: DR Toolbox III: Structured Reflection Exercise (SRE) 4
5 Part I: Introduction to Diagnostic Reasoning
6 Learning Objectives - Understand the what and why of Diagnostic Reasoning - Recognize dual-process theory s role in how we reason 6
7 What is Diagnostic Reasoning? - Clinical reasoning - The process of thinking and decision making, consciously & unconsciously guide practice actions 25yo female G1P0, 2m gestation returns from Rio. - Diagnostic reasoning: - The process of collecting & analyzing information establish a diagnosis chest pain STEMI in proximal LAD abdominal pain acute appendicitis 7
8 Why teach diagnostic reasoning? - Incorrect diagnoses are often at the root of medical errors - DR is a means to apply basic science to clinical problems - Central to being a physician 8
9 Patient s perspective What s wrong with me? Is it bad? What can we do about it? 9
10 Why now? Never too early for practice 10
11 From Novice to Expert 11
12 How do we reason? Information processing theory 12
13 How do we reason? Information processing theory: Dual process theory. Analytical Conscious Type/System 2 Slow Effortful Deliberative Logical Requires attention, self-control, time. Hypothesis-driven, Bayesian (probability) Non-analytical Unconscious Type/System 1 Fast Automatic Involuntary Emotional Executes skilled response and generates intuition with minimal effort Pattern recognition (illness scripts) Heuristics 13
14 From Novice to Expert Non-Analytical Analytical 14
15 Can you learn/improve diagnostic reasoning? Nonanalytic diagnostic reasoning Analytic diagnostic reasoning 15
16 Caveats Diagnostic reasoning is a skill that improves with practice It is highly individualized both by the physician and for each given patient case An ever growing fund of knowledge is critical 16
17 Part II: Diagnostic Reasoning Toolbox
18 Learning Objectives - Review principles for teaching DR to students - Define key terms in teaching DR - Review tips for leading teaching session 18
19 Principles for teaching DR to clinical students 1. Student should be familiar with typical presentations of common diseases. Start to incorporate atypical presentations of common diseases, gradually increasing complexity. 2. Explicitly discuss clinical reasoning processes during case discussions. 19
20 Definitions Illness script Scheme induction Problem lists Problem representation/summary statement Framework Differential diagnosis Scaffolds 20
21 Definitions Illness script Scheme induction Problem lists Problem representation/summary statement Framework Differential diagnosis Scaffolds 21
22 Illness scripts Mental constructs of disease manifestations. The internal rolodex of diseases. How we store disease prototype in order to then use it for pattern recognition. Non-analytical Unconscious Type/System 1 Fast Automatic Involuntary Emotional Executes skilled response and generates intuition with minimal effort Pattern recognition (illness scripts), Heuristics Odds are you have a lot of these, but students have few, immature ones 22
23 Illness scripts Non-analytical Unconscious Type/System 1 Fast Automatic Involuntary Emotional Executes skilled response and generates intuition with minimal effort Pattern recognition (illness scripts), Heuristics 23
24 Definitions Illness script Scheme induction Problem lists Problem representation/summary statement Framework Differential diagnosis Scaffolds 24
25 Scheme induction A systematic application of rules to narrow the differential diagnosis of a symptom, sign, or lab. Analytical Conscious Type/System 2 Slow Effortful Deliberative Logical Requires attention, self-control, time. Hypothesis-driven, Bayesian (probability), Worst-case scenario, 25 EBM
26 Definitions Illness script Scheme induction Problem lists Problem representation/summary statement Framework Differential diagnosis Scaffolds 26
27 Problem lists Lawrence Weed A mechanism to summarize the state of a patient s health in written documentation. Many uses. They can evolve within a history and across encounters. Warning: Don t lose the big picture. Use precise language Features of Effective Problem Lists Update and modify over time Prioritize Make associations between problems 27
28 Definitions Illness script Scheme induction Problem lists Problem representation/summary statement Framework Differential diagnosis Scaffolds 28
29 Problem representation/summary statement/one-liner/impression The description of the patient s presentation. 3 Critical Components of Problem Representation Clinical context Temporal pattern Key clinical symptoms and exam findings that relate to presenting symptoms. Example 1: Mr. Smith is a 64-year-old man with the ischemic cardiomyopathy who presents with a two day history of gradual onset, worsening dyspnea on exertion and findings of hypoxia, bilateral crackles, elevated JVP, and lower extremity edema. Example 2: Ms. Jones is a 33-year-old woman with a history of heavy alcohol use and NSAID use who presents with two days of severe, burning, and midepigastric abdominal pain and acute melena. Her examination is notable for hemodynamic instability, soft, nontender abdomen with normal bowel sounds, no organomegaly or jaundice, normal rectal exam, but positive stool heme testing. 29
30 Problem representation/summary statement/one-liner vs. illness script Very similar! And use patients to build illness scripts! Patient-specific vs. disease-specific. Both benefit from semantic qualifiers. 30
31 Definitions Illness script Scheme induction Problem lists Problem representation/summary statement Framework Differential diagnosis Scaffolds 31
32 Framework A means of building differential diagnoses. NOT patient-specific. Examples: Worst-First Approach Mnemonics (e.g., VINDICATE) Organ System- or Anatomic-based 32
33 Differential diagnosis Potential etiologies of a given patient problem. 33
34 Worst-First Framework Ask yourself: Is this life-threatening? Does this patient need to be in an ED? 34
35 Worst-First Examples Chest pain: ACS vs. Aortic Dissection vs. PE vs. esophageal rupture vs. other non-life threatening Dyspnea: MI vs. CHF vs. COPD vs. asthma vs. PTX vs. PE Abdominal pain: pancreatitis vs. perforated viscus vs. Mallory Weiss tear vs. cholangitis vs. GERD Hematochezia: variceal bleed vs. diverticulosis vs. hemorrhoids vs. colon cancer vs. brisk upper GI bleed 35
36 VINDICATE V I N D I C A T (mnemonic Framework) Vascular Infectious Neoplastic Drugs Inflammatory, Idiopathic Congenital Autoimmune/Allergic Traumatic (including psychological trauma) 36 E Endocrine
37 VINDICATE for CC: Altered Mental Status Vascular Stroke (ischemic/ hemorrhagic) TIA HTN encephalopathy Infectious Encephalitis Meningitis Sepsis Neoplastic 1 or metastatic tumor Drugs/Toxins Overdose/ Withdrawal 37 Inflammatory SIRS, vasculitis, pancreatitis, endocarditis Congenital Epilepsy Autoimmune Seizure in lupus patient Trauma Subdural bleed Endocrine Hypo/hyperglycemia Hypo/hypernatremia Uremia, ammonia Hyper/hypothyroid
38 Organ System or Anatomic-Based Approach Define complaint anatomically If systemic disease, identify specific anatomic involvement Be thorough 38
39 Anatomic Approach to Chest Pain Skin? Muscle? Ribs? Pericardium? Myocardium? Coronary vessels? Pleura? Lung parenchyma? Pulmonary vessels? Esophagus? By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)bartleby.com: Gray's Anatomy, Plate 492, Public Domain, p?curid=
40 Definitions Illness script Scheme induction Problem lists Problem representation/summary statement Framework Differential diagnosis Scaffolds 40
41 Scaffolds: how to develop students reasoning skills. OLD CARTS Schema Problem Lists SRE 41
42 Definitions Illness script Scheme induction Problem lists Problem representation/summary statement Framework Differential diagnosis Scaffolds 42
43 Part III: Structured Reflection Exercise (SRE)
44 Learning Objectives - Review the evidence-based method for assessing diagnostic reasoning 44
45 ACS CAD risk factors 30 years old 45
46 Summary Increase faculty familiarity with diagnostic reasoning principles and tools so as to improve its teaching.
47 Three Parts: I: Introduction to Diagnostic Reasoning II: DR Toolbox III: SRE 47
48 Questions? Heather Hofmann, 48
49 References Gordon, D., & Guth, T. (2013). Clinical Reasoning in Medical Students : Retrieved from AA/2013 Day Two/Deliberate Metacognition.pdf Kearney-Strouse, J. (2015). Clinical reasoning now a foundational basic science in medical education. ACP Hospitalist. Khullar, D., Jha, A. K., & Jena, A. B. (2015). Reducing Diagnostic Errors Why Now? New England Journal of Medicine, 363(1), Levin M, Cennimo D, Chen S, Lamba S. Teaching clinical reasoning to medical students: a case-based illness script worksheet approach. MedEdPORTAL Publications. 2016;12: Modi, J. N., Gupta, P., & Singh, T. (2015). Teaching and Assessing Clinical Reasoning Skills. Indian Pediatrics, 52(9), Outpatient Diagnostic Errors Affect 1 in 20 U.S. Adults, AHRQ Study Finds. Content last reviewed April Agency for Healthcare Research and Quality, Rockville, MD. Toy, E., & Patlan, J. (2012). Case Files Internal Medicine. Trowbridge, R., Rencic, J., & Durning, S. J. (Eds.). (2015). Teaching Clinical Reasoning. ACP. Wolpaw, T. M., Papp, D. R., & Klara, K. (2016). Academic Medicine : SNAPPS : A Learner centered Model for Outpatient Education, 78(9),
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