Cognitive approaches to CDR

Transcription

1 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 Associate Dean for Medical Education Pacific Northwest University of Health Sciences Cognitive approaches to CDR Analytical Hypothetico-deductive Deliberate, purposeful thinking Acquired, critical, logical thinking Robust decision making Intuitive Experiential-inductive Unconscious thinking Heuristic Pattern recognition Croskerry, Acad Med 2009

2 Clinical reasoning strategies Hypothesis testing Pattern recognition Forward thinking Baker et al. Acad Int Med Insight 2010;8;12-17 Forward Thinking Angina Exertional Intermittent Nonexertional Chronic Continuous Chest Pain Acute Baker et al.

3 Novice Expert Lucey C % 0 % Novice Expert Baker et al.

4 Reporting Milestone #1 Gathers and synthesizes essential and accurate information to define each patient s clinical problem(s) Bowen JL. NEJM 2006

5 Problem Representation A brief summary where patient specific details are translated into appropriate medical terminology (i.e. medicalese). The patient s story My knee hurt me so much last night, I woke up from sleep. It was fine when I went to bed. Now it s swollen. It s the worst pain I ve ever had. I ve had problems like this before in the same knee, once 9 months ago and once 2 years ago. It doesn t bother me between times. Bowen NEJM 2006

6 The Problem Representation The acute onset of a recurrent, painful, monoarticular process in an otherwise healthy middle-aged man. Bowen NEJM 2006 Patient specific Abstract terms fine when I went to bed = acute onset I ve had problems like this before = recurrent same knee = monoarticular

7 Semantic qualifiers (SQ s) Paired, opposing descriptors that can be used to systematically compare and contrast diagnostic considerations. Bowen NEJM 2006 Semantic qualifiers (SQ s) Sudden/Gradual Recurrent/Isolated Single/Multiple Severe/Mild Acute/Chronic Pruritic/non-pruritic Immediate/Delayed Localized/diffuse Sharp/dull Tender/non-tender Productive/non-productive Painful/painless Stuart, et. Al. ACE

8 Forward Thinking Angina Exertional Intermittent Nonexertional Chronic Continuous Chest Pain Acute Lucey, Baker Uses collected data to define a patient s central clinical problem(s)

9 The patients Problem Representation IS their Central Clinical Problem! What s next?

10 You need a Diff Dx GERD ACS PE Aortic Dissection

11 What is an Illness Script? A narrative structure for recalling the key attributes of a typical presentation (case) of a condition or diagnosis. Charlin. Acad Med, 2000 Models of Illness Scripts Enabling conditions Fault (Pathophysiologic insult) Clinical consequences Epidemiology Temporal course/ pattern Key features of the disease Charlin 2000, van Schaik 2005, Lucey 2002 Bowen 2006

12 For Example Epidemiology Temporal Qualitative Lucey 2002 healthy vs. immuncompromised acute vs. chronic progressive vs. stable severe vs. mild pleuritic vs. nonpleurtic mono vs. polyarticular localized vs. systemic Learn in the style you will use the knowledge G Bordage Teach your learners to organize what they read and see in a structured format every time.

13 Pattern Recognition Matching the patient s problem representation to an appropriate illness script

14 How to prioritize your DDx Compare/contrast different illness scripts with the patients PR looking for best match. Base rates Rule out worst case scenario M6 Effectively uses history and PE skills to minimize the need for further diagnostic testing

15 Slide 28 M6 Are your steps in the previous slides benchmarks for this? Michele, 4/2/2013

16 How strong of a match do you have? Tier I Diagnosis: Disease illness script matches the patient s illness script almost perfectly Tier II Diagnosis: The patient is missing key features of the disease The disease does not explain prominent features of the patient s presentation Tier III Diagnosis: Single or pauci clue match Lucey, 2002 The critical elements of CDR include: 1. Efficient data collection using forward thinking 2. A good Problem Representation (appropriate terminology, SQ s) 3. Illness scripts stored in the same format 4. Prioritizing illness scripts 5. Identifying high probability (Tier 1) diagnoses

17 Heuristics & Cognitive Errors Heuristics Rules of thumb Strategies that provide short cuts to quick decision-making They help make complex tasks simpler. They make us more efficient. Typically unconscious

18 Heuristics Availability heuristic Representativeness heuristic Cognitive Errors Premature closure Confirmatory bias Diagnosis momentum

19 Graber et al. Arch Intern Med 2005 One hundred cases of diagnostic error involving internists were identified through autopsy discrepancies, quality assurance activities, and voluntary reports 5.9 factors involved/case Graber et al. Arch Intern Med 2005 Cognitive errors involved 39: Premature closure 23: Failed heuristics 14: Failure to realize there was more than 1 diagnosis 10: Failure to periodically review the situation 10: Overreliance on someone else s opinion

20 Cognitive Forcing Strategies Universal: Metacognition Generic: Understanding the major classes of heuristics, biases. Specific: Identifying pitfalls (common situations prone to specific cognitive errors) Croskerry Ann Emerg Med 2003 Structured reanalysis Review the original diagnosis List the findings that support the diagnosis List the findings that argue against the diagnosis List the findings that would be expected to be present if the diagnosis were true but were not described in the case. Mamede. JAMA 2010

21 The Role of Checklists Ely, Graber, Croskerry The critical elements of CDR include: 1. Efficient data collection using forward thinking 2. A good Problem Representation (appropriate terminology, SQ s) 3. Illness scripts stored in consistent format 4. Prioritizing illness scripts 5. Identifying high probability (Tier 1) diagnoses 6. Structured reanalysis

22 How do we teach CDR? Make it an explicit part of the curriculum. Teach your learners a structured process, to include debiasing strategies. Model your CDR process. Aloud. All the time. How do we evaluate CDR? Provide opportunities for your learners to demonstrate their CDR skills ALOUD on rounds. Don t settle for a correct diagnosis. Stretch it Have your learners consistently state a Problem Representation.

23 Provide opportunities for your learners to demonstrate CDR in their write-ups. I Interpretive summary D Differential diagnosis with commitment to the most likely diagnosis E Explanation of reasoning in choosing the most likely diagnosis A Alternative diagnoses with explanation of reasoning Baker EA, JGIM 2003 How do we document CDR? Include it in your evaluation form.

24 In summary Clinical diagnostic reasoning is typically an unconscious and unobserved process. We have to make it a conscious, observable process. We need to explicitly teach our residents the skills of forward thinking, pattern recognition and structured reanalysis. We need to explicitly model these skills for our residents on a daily basis.

25 In summary We need to provide our residents continuous opportunities to demonstrate their CDR skills. Never settle for just getting the right diagnosis. The critical elements of the CDR process should be included in both the resident s rotation curriculum and their evaluation forms.