Reinventing Report: How You Can Develop Resident Expertise in High- Value Clinical Reasoning

Transcription

1 Reinventing Report: How You Can Develop Resident Expertise in High- Value Clinical Reasoning Jason H. Maley, MD, Kathleen M. Murphy, MD, and Erin M. Haley, MD, PhD Chief Medicine Residents Department of Medicine Hospital of the University of Pennsylvania Philadelphia

2 Objectives Describe the key elements of clinical reasoning Apply skills to highlight metacognition: thinking about how you think Understand the connection between clinical reasoning and value, through discussion of thoughtful diagnostic approaches

3 Simulating Report

4 How is report different than bedside rounds?

5 Education is not the learning of facts, but the training of minds to think ~Albert Einstein

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7 Thinking Fast Type 1 Reasoning 55 year old man presents with 3 months of cough 15 lb weight loss hemoptysis household contacts with tuberculosis non - smoker

8 Thinking Slow Type II Reasoning 45-year-old man, non-smoker, presents with 1 month of progressive dyspnea on exertion and lower extremity edema

9 CLINICAL REASONING ROUNDS The Returned Traveler

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11 Type 1 Reasoning Thinking Fast

12 Type 2 Reasoning Thinking Slow

13 Essential Elements

14 A 28 year-old woman was admitted to the hospital in August with 5 days of fevers, and generalized malaise. She reported being in good health at baseline, without any past medical history. She returned 10 days earlier from a 3-week long family trip to visit relatives in India. Leading up to this illness she denied any prodrome of symptoms. Since returning from India, she had gone back to studying as she was in law school at the time and felt well initially. She lived in southern NJ, and her only notable activities since returning included jogging in a nearby park each morning. She otherwise had been spending most of her time indoors since returning. Then, 5 days prior to presenting to the ED, she began to experience fevers, which she measured up to 102 at home and she reported nausea, vomiting, headache, myalgias and profound fatigue associated with the symptoms over the same time course.

15 Type a quote here. Johnny Appleseed

16 A healthy young woman, active in outdoor activities in NJ, with 5 days of Mlu-like illness after returning from a 3 week trip in August to visit relatives in India.

17 Pivotal Piece

18 Fever in a returned traveler from India

19 Approach

20 Fever in a returned traveler from India Related Typhoid Malaria Dengue Chikungunya Rikettsia Leptospirosis Hepatitis Unrelated Summer-time flu-like illness Rheum Malignant

21 Type a quote here. Johnny Appleseed

22 Cognitive Bias Anchoring Confirmation Recency

23 Hypothesis Generation and Testing

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25 Debrief and Summary Steps of Reasoning Biases Approach Questions

26 HIGH VALUE CARE COMPETITION The Farmer s Lungs

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29 Teaching for Retention Know your Audience Pace and Pauses Tone Repetition Less is More

30 Summary Teach students how to swing, don t just show them where the ball should land Teach methods and performance NOT simply facts Choosing tests wisely requires a foundation of clinical reasoning

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32 The Art of Diagnosis: Internal Medicine Clinical Reasoning The Farmer s Lungs Learning Objectives: - Compare and contrast the intuitive (type 1) and analytical (type 2) approach to clinical reasoning - Formulate a summary statement from a complex presentation - Employ a step-wise, hypothesis driven approach to test ordering - Understand the role of analytical clinical reasoning in high value care - Understand and apply a systematic approach to the complaint of dyspnea Case: Mr. P is a 43-year-old dairy farmer from Lancaster, Pennsylvania who presented to the emergency department with a 2-week history of progressive dyspnea with exertion. He stated that he had been healthy all of his life, until recently when he began to notice difficulty doing his daily chores because he was becoming short of breath easily. He states that most mornings he would wake up early to walk up a large hill to his barn, and noticed that over the past 2 weeks he had to stop and rest midway up the hill to catch his breath. He had never experienced shortness of breath like this in his life, and reported that it occurred at all times of the day with even moderate exertion. The dyspnea was relieved by rest after a few minutes each time. He also noted new edema of the lower legs, a nonproductive cough, and some dark specks in the sputum recently that he thinks could blood. over the same period of time. He reported no recent upper respiratory tract infection, fever, weight loss, abdominal pain, hematuria, chest pain, or hematemesis. He denied orthopnea or paroxysmal nocturnal dyspnea. He had no recent travel, known malignancy, or history of venous thrombosis. He had never been homeless, and had only spent a week in jail once on a DUI charge. The patient's medical history included hypertension. His only medication was amlodipine. He was a heavy smoker and reported occasional marijuana use and a history of excessive drinking, but he said he did not currently drink alcohol or use intravenous drugs. His farm was primarily in the dairy business, and had many cows, several dogs and 2 cats in his home. He lived with his wife, a schoolteacher, and 2 young children, all of whom were healthy and without similar symptoms. He did not do any agricultural farming and had no silo on his land. He had never traveled outside of Pennsylvania. On admission, his temperature was 37 C, the heart rate 84 beats per minute, the respiratory rate 24 breaths per minute, the blood pressure 158/84 mm Hg, and the oxygen saturation 91% on room air. There was conjunctival pallor and dried blood in the oropharynx. Crackles were heard at both lung bases. The cardiac examination was unremarkable. The jugular venous pressure was 6 cm. The patient's abdomen was not tender and there was no organomegaly or ascites. A rectal examination revealed external hemorrhoids. There was 1+ pitting edema up to the knees. Mr. P s skin was warm and dry, without evidence of nodules, rash, or petechiae. There was no joint swelling or tenderness and no lymphadenopathy. The neurologic examination was normal.

33 Can you figure out the cause of this young and previously healthy man s severe dyspnea? TEAM NAME 1) Summary Statement: individually write a statement that summarizes the essential elements into a single sentence. Remember to include the most relevant aspects, use medical terminology, and use semantic qualifiers. As you purchase test results, add important elements to and revise this summary statement. 2) Pivotal Element: pick the most unique or approachable aspect of the case to build a differential around (e.g. acute chest pain) 3) Write the top 5 diagnoses (can be broad categories) on your differential, ranked from most likely to least likely. Discuss the illness scripts around each differential diagnosis to help inform prioritization and diagnostic testing ) Tally money spent on testing: 5) List your final Diagnosis:

34 Clinical Reasoning Rounds Returning Traveler A 28 year-old woman was admitted to the hospital in August with 5 days of fevers, and generalized malaise. She reported being in good health at baseline, without any past medical history. She returned 10 days earlier from a 3-week long family trip to visit relatives in India. Leading up to this illness she denied any prodrome of symptoms. Since returning from India, she had gone back to studying as she was in law school at the time and felt well initially. She lived in southern NJ, and her only notable activities since returning included jogging in a nearby park each morning. She otherwise had been spending most of her time indoors since returning. Then, 5 days prior to presenting to the ED, she began to experience fevers, which she measured up to 102F at home and she reported nausea, vomiting, headache, myalgias and profound fatigue associated with the symptoms over the same time course.