What Every Chief Resident Should Know About Clinical Reasoning

Transcription

1 What Every Chief Resident Should Know About Clinical Reasoning Joseph Rencic, MD, FACP Tufts Medical Center, Tufts University School of Medicine Conflict of interest statement I will be discussing some commercial products but I obtain no revenue from any of these.

2 Objectives Define clinical reasoning and its components Differentiate analytic and non analytic clinical reasoning Develop strategies for teaching analytic and non analytic clinical reasoning in diverse contexts Clinical reasoning defined (sort of) the cognitive and physical process by which a health care professional consciously and unconsciously interacts with the patient and environment to: collect and interpret patient data weigh the benefits and risks of actions, and understand patient preferences Purpose: to determine a working diagnostic and therapeutic management plan to improve a patient s well being

3 Dual Process Reasoning Two cases

4 Case 1 Pattern Recognized Non-analytic reasoning (NAR) Patient Presentation Personal Pattern Processor Diagnosis Dual process theory schematic Learning non analytic reasoning Categorization by matching to a known concept Match illness scripts (e.g., mental constructs of diseases) to clinical findings How do people learn categories? Personal experience Exemplars Others experiences Prototypes Repeated cycles of comparison and contrast with feedback

5 Case 2 Patient Presentation Pattern Recognized X Personal Pattern Processor Non-analytic reasoning (NAR) Diagnosis Pattern Not Recognized Analytic reasoning (AR) Dual process theory schematic Data collection Hypothesis generation Illness script knowledge Problem representation CONTEXT Patient factors, Environment, Physician factors Treatment Script Selection (Diagnosis) Components of clinical reasoning

6 CONTEXT Patient factors, Environment, Physician factors Data collection Hypothesis generation Problem representation Illness script knowledge Treatment Script Selection (Diagnosis) Goal: Find the disease that best explains the clinical findings Types of analytic reasoning Richardson WS. Contemporary endocrinology, 2006, p. 69.

7 Learning analytic reasoning Requires understanding and deliberate practice Learning pathophysiology Learning Bayesian reasoning Evolution: expert clinical reasoning performance Typical presentations of common diseases Typical presentations of uncommon diseases AR NAR + AR Pathophysiological knowledge with limited clinical experience Illness script knowledge informed by clinical experience Schmidt. Med educ (2015):

8 You know you re in trouble when your Mr. Osborne Teaching Clinical Reasoning

9 Challenges of teaching clinical reasoning Fundamental teaching principle Solution: Create authentic, case based learning exercises Sulaiman. suehaina1/transfer of learning

10 Context specificity Solution: Maximize exposure to various disease presentations in multiple contexts General teaching recommendation Think out loud You Learning session participants Why did you ask that?

11 Specific recommendations: Diagnostic morning report: a case study Morning report (MR) and the challenges Pros Uses real cases Can present wide spectrum of typical and atypical presentations of common and uncommon diseases within given chief complaints Cons Inauthentic context Individual engagement variable

12 Begin with the end in mind Resident graduate s clinical reasoning ability: Should consist of broad and deep illness scripts in multiple contexts Should have flexibility in reasoning Should include the knowledge of when to ask for help habit2.php Exercise Keeping in mind the end product and the challenges of transfer and context specificity: List three realistic ways that you can enhance clinical reasoning teaching in your morning report Discuss with your neighbor

13 Key take home: teach illness scripts Acute Coronary Syndrome Pericarditis Pulmonary embolism Epidemiology Older age, cardiac risk factors Uremia, auto-immune disease, prior URI, recent MI or heart surgery, malignancy Virchow s triad Time Course Acute onset, not necessarily preceded by exertional angina Acute, but may occur in setting of sub-acute or chronic disease Acute onset usually without progression, unless second PE Clinical Features (1) History (2) Exam (3) Labs (4)Imaging Advanced Studies 1) Chest pain, with crescendo to maximal pain; often dull and substernal, radiating to arms/shoulders; diaphoresis; dyspnea; nausea/vomiting, diaphoresis. 2) Tachycardia 3) Elevated cardiac biomarkers (troponin/ck), abnormal ECG (ST elevation/ depression, T wave changes) 4) Regional wall motion abnormality on echocardiogram 1) Sharp, stabbing chest pain radiating to back and trapezius ridge; improved with sitting forward 2) Pericardial friction rub (may be ephemeral, more pronounced with sitting forward) 3) Abnormal ECG (diffuse ST elevation, PR depression); elevated inflammatory markers (ESR, CRP) 4) Common: Pericardial effusion on echo or CT 1) Shortness of breath, pleuritic chest pain 2) Tachycardia; tachypnea; normal lung exam, 3. Common: positive D-dimer 4. X-ray with minimal abnormalities; CT chest with pulmonary angiogram demonstrates a clot; V/Q scan with unmatched perfusion defect Teaching scripts: problem representation Define problem accurately (i.e., problem representation) Define key problem(s) Create a list of key diagnostic findings for each problem Prioritize based on sensitivity/specificity(likelihood ratios) Note: Epidemiology and risk factors count! Tell your neighbor why listing key findings is so important in a diagnostic morning report case.

14 Example 36 yo female with no significant PMH, SH, FH, or med use other than tobacco use (1/2 PPD) and OCPs who presents with progressively worsening DOE with subjective fever, nonproductive cough, pleuritic, posterior lower right chest pain, and myalgias. Poor PO intake. PE: 38.1, 90/50, 112, 20, sat 94%. Only finding: crackles and egophony in RLL Key problem: Progressive dyspnea on exertion Key findings: Why are key findings key? Increase or decrease likelihood of disease I.e., Moderate to strong likelihood ratios Examples: Non productive cough Useless OCP Useful Egophony Useful Hypotension Useless

15 Likelihood ratios (LR) Your hospital s finished product must understand the value of tests T or F Quiz 1. Phalen s sign has a moderately strong LR for ruling in carpal tunnel. 2. Egophony has a better likelihood ratio positive for ruling in pneumonia than a nuclear stress test for ruling in obstructive CAD. 3. An ACE level of 75 has limited utility in ruling in sarcoidosis. Resources The Likelihood Ratio Database DxLogic LR digression Medicine tool kit app Rational clinical examination series, JAMA The NNT

16 Teaching hypothesis generation/differential Dx Non analytic approaches Generating key finding list may allow learners to visualize a subtle pattern Analytic approaches Causal reasoning Pathophysiology of clinical findings explains disease of interest Probabilistic reasoning Common things being common Checklists Systems approach Disease categories (e.g., VINDICATE) Pain free differential diagnosis Respondents must: Relate diagnosis to key findings (stresses matching) Likely diagnoses Life threatening diagnoses Limit diagnoses discussed to can t miss, 50%, 80% State probability estimates explicitly Benefit: More meaningful, detailed discussions of fewer diagnoses

17 Teaching script selection/diagnosis Compare and contrast the 2 or 3 most likely diagnoses on differential diagnosis Key characteristics of correct diagnosis Coherence Adequacy Parsimony Key findings are relative to the problem E.g., Our case myalgias were a key finding in making pulmonary infarct much less likely Teaching script selection/diagnosis Hypothesis driven laboratory and radiologic studies Don t just jump to labs, studies Consider a script selection table

18 Our case 36 yo progressive DOE Myalgias Relative hypoxia Egophony Smoking OCP use Differential diagnosis 80% Pneumonia, viral vs. bacterial Can t miss Pulmonary infarct Poor choices: Anemia Anxiety Note: This teaching approach readily transfers to ward or clinics. Script selection table Key findings Pneumonia Pulmonary infarct 3 day progressive course ++ Myalgias ++ Egophony + + OCP use + smoking n/a + Low grade fever ++ + Relative hypoxia + +

19 MR Results Learning within MR Potentially successful? Building deep and broad illness scripts Improving diagnostic flexibility Recognizing when to call for help +/ Whither therapeutic reasoning? What are the challenges of teaching therapeutic reasoning? Obvious therapies are obvious No gold standard for non evidence based therapeutics or uncertain contexts Thresholds to treat typically subjective Role modeling (e.g., panel discussion) Will this test change my management? Threshold to test Threshold to treat with heparin Probability of disease

20 Additional Opportunities for Teaching Clinical Reasoning Where else do you teach clinical reasoning?

21 Analytic reasoning: diagnostic error Morbidity and mortality Cognitive error Heuristics and biases Analytic reasoning: Morbidity and mortality Metacognition Situation awareness Cognitive forcing strategies Specific to chief complaint Expert accuracy 1 Ark Med Educ 2007, 2 Mamede Psychol Res 2010

22 Non analytic reasoning: individual or team challenges Visual diagnosis Daily/weekly image challenge Physical diagnosis rounds Case of the month The individual learner Direct observation essential Bedside teaching Diagnose the learner

23 Conclusions The goal of teaching clinical reasoning is a physician with a broad and deep understanding of illness scripts who can is flexible in using nonanalytic or analytic reasoning strategies Morning report provides an excellent venue for role modeling clinical reasoning We should teach both non analytic and analytic approaches to enhance our learners clinical reasoning abilities Conclusions Teaching clinical reasoning is a critical part of a chief resident s job In your clinical reasoning teaching sessions: Make clinical reasoning processes explicit (e.g., think aloud ) Hammer home illness scripts

24 Useful readings Bowen, Judith L. "Educational strategies to promote clinical diagnostic reasoning." New England Journal of Medicine (2006): Eva, Kevin W. "What every teacher needs to know about clinical reasoning." Medical education 39.1 (2005): Questions?

25 LR simplified LR + = sensitivity/1 specificity = TP/FP (rate) LR = 1 sensitivity/specificity = FN/TN (rate) Likelihood ratio + Change in probability Likelihood ratio Return Non analytic reasoning Advantages Fast Effortless Low cost Automatic Potential disadvantages Dependent on context Highly subject to affective state Dependent on heuristics Not all patterns are recognizable Dependent on experience

26 CONTEXT Patient factors, Environment, Physician factors Data collection Hypothesis generation Problem representation Illness script knowledge Treatment Script Selection (Diagnosis) Data collection and hypothesis generation 36 year old with history of tobacco and oral contraceptive use presents with acute dyspnea You immediately think of... This leads you to ask... But then the vital signs reveal a fever of and you immediately think of...

27 Problem representation Assessment/summary statement Mrs. is a *AGE* *SEX* with a history significant for *RELEVANT PAST MEDICAL HISTORY*^ who presents with *SYMPTOMS, SIGNS, PERTINENT LABORATORY AND RADIOLOGICAL FINDINGS* consistent with *DIAGNOSIS(ES)* ^ Note: This should include important medications, social history, and family history How does non analytic reasoning work? Illness scripts form the basis for patterns that we seek to make diagnoses Heuristics Mental shortcuts based on illness scripts that physicians use to make diagnoses

28 Conundrum Resident 1 99 th percentile on USMLE Resident 2 50 th percentile on USMLE You fear for patients lives when he is within a 10 radius of them You would feel comfortable having her care for your mother Analytical Reasoning Types What is it? How do you do it? Bayesian reasoning Inference to the best explanation Causal reasoning The search for the most probable diagnosis (i.e., the likeliest explanation ) The search for the diagnosis with the greatest explanatory power (i.e., the loveliest explanation ) Use prevalence, pre test probability estimation, likelihood ratios, algorithms Seek hypotheses that best explain the clinical findings to prove them correct (i.e., pathophysiological thinking)

29