Deliberate Practice. Just in Time Teaching. Just in Time Deliberate Practice. Using Deliberate Practice To Teach Problem Solving.

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1 Teaching of Tomorrow November 19, 2016 Using Deliberate Practice To Teach Problem Solving Scott Wellman, MD Director Clinical Faculty Development Center Director Center for Academic Achievement University of Massachusetts Medical Center Summary Deliberate Practice Just in Time Teaching Where we re headed Just in Time Deliberate Practice 1

2 Practice Makes Perfect? The admonition that practice makes perfect was not true. Practice only makes permanent. The type of practice carried out makes the difference between expert development and the maintenance of mediocrity. Pelley Objectives 1. Generate Problem Representations 2. Illness Scripts (Tool to learn about diseases and to differentiate among them) 3. Deliberate Practice (Utilize strategies to teach Clinical Reasoning at the point of care 2

MAKE CONNECTIONS Key Elements of the Clinical Diagnostic Reasoning Process Judith

3 Additional Objectives Clinical Problem Solving CONCEPTS: 1. ACTIVATED FINDINGS 2. GROUPED FINDINGS 3. ACTIVATE PRIOR KNOWLEDGE 4. MAKE CONNECTIONS Key Elements of the Clinical Diagnostic Reasoning Process Judith Bowen, MD NEJM 2006; 355: Patient s Chart on Door (or EHR) Diagnosis I think you should be more explicit here in step two. 3

4 Patient s Chart on Door Generate Hypotheses Patient s Story Patient s Chart on Door Generate Hypotheses Patient s Story Problem I was completely well Representation till this AM Acute, severe Problem Representation Patient s Story The pain was so bad I almost passed out I was completely well till this AM Acute, severe 4

5 illness Script Patient s Chart on Door Generate Hypotheses Patient s Story Problem Representation Diagnosis illness script Questions? 5

Let s solve some problems Participants break into groups Work through a case Discuss together What strategies are used in our own CPS? How would you teach this?

6 Let s solve some problems Participants break into groups Work through a case Discuss together What strategies are used in our own CPS? How would you teach this? Case 1 List Findings 27 yo male Unemployed T 40; sweating; sick Cat bite Transient vision loss Case 1 List Findings 27 yo male Unemployed T 40; sweating; sick Cat bite Transient vision loss 6

7 Case 1 List Findings: Hx Activate Prior Knowledge 27 yo male Unemployed T 40; sweating; sick Cat bite Risk factors Drugs Infectious Infectious S.Aur Strep P. Multocida Cat Scratch Transient vision loss Neuro/vascular Practice Recall Case 1 List Findings: PE Exercise: What could you ask/teach your learners P 124; BP 110/40 Bounding pulse II/VI diastolic murmur at the Lt 3 rd ICS Case 1 List Findings: PE JiTT Questions: P 124; BP 110/40 Bounding pulse II/VI diastolic murmur at the Lt 3 rd ICS AI PDA Hyperthyroid Sepsis Sick; High pulse pressure Aortic Insufficiency 7

8 Review Teach students to: List Findings Activate Prior Knowledge Practice recall Ask Self Questions or JiTT Q s Problem Representation Problem Representations Problem Representation It is a one liner The gist of the case The essence of the case It is what makes this case endocarditis 8

9 Problem Representation Transform the patient specific details into precise, succinct, terms Adjectives, adverbs, descriptors semantic qualifiers Non-bilious, Non-bloody, Vomiting PR Components Paints a picture of the patient Let s you know how sick Leads you to the diagnosis It is terse Semantic Qualifiers Usually on a bipolar axis 9

When she would start to cough she had trouble stopping it and felt that she could not catch her breath. It seemed to be worse at night.

10 Bipolar Axes Sick Not Sick Mild Severe Acute Chronic Febrile NOT Febrile OP of HPI: Cough 45 year old female presents with 45 days of coughing. It began 45 days ago when she developed a runny nose, sneezing, and cough. Her eyes also felt irritated. The next week, the cough got much worse. When she would start to cough she had trouble stopping it and felt that she could not catch her breath. It seemed to be worse at night. After a while she chose to sit in a chair to sleep. It got so bad that a few times she actually wet herself during a coughing fit. Etcetera. Problem Representation: Cough Middle aged woman with severe, paroxysmal, chronic cough, beginning one week after an upper respiratory prodrome. 10

11 Value of PR Better problem solving Why? Better retention Signout Call consultant History: Knee Pain 65 year old man woke up in the middle of the night with severe knee pain. This has happened before a couple of times. Often it occurs after he s had red wine. Translate the above patient s description of the problem into doctor-ese, a problem representation using semantic qualifiers. Problem Representation 65 year old man woke up in the middle of the night with severe knee pain. This has happened before a couple of times. Often it occurs after he s had red wine. 11

12 Illness Scripts Illness Script Gout Epidemiology: yo; male; Alcohol/red meats/diuretics Pathophysiology: Abnl Uric acid metabolism precipitation of crystals in joint Inflammation Clinical Consequences: Hx: Acute, recurrent, severe, mono articular, classically 1 st MPJ. PE: Red, hot, swollen, warm, tender Illness Script Arthritis Epidem Gout Septic Arthritis Lyme RA Osteo Arthritis Pathophys Hx: PE: 12

Use Illness Scripts Contrast hypotheses Write precise, accurate problem representations Do this

13 Illness Script Arthritis Epidem Pathophys Gout Wine, red meat Septic Arthritis Lyme RA Osteo Arthritis Tick bite Autoimmune Hx: PE: Recurr Severe Noctrnl Not Recurr Severe Const Not Severe Use Illness Scripts Contrast hypotheses Write precise, accurate problem representations Do this Deliberately Summary Conclusion Thinking is not a reflex but can be monitored and regulated deliberately. 13

14 Questions? 14

Cognitive approaches to CDR

Cognitive approaches to CDR Occam s Razor and Other Two-edged Swords: Teaching Residents Clinical Diagnostic Reasoning Jack DePriest, MD, MACM Program Director, Internal Medicine Residency CAMC-WVU Michele Haight, PhD, MS Ed, MACM