Diagnostic Reasoning “DR” Toolbox for Hospitalist Faculty
Heather Hofmann, MD Department of Medicine 2017-18 2 Goal Increase faculty familiarity with diagnostic reasoning principles and tools so as to improve its teaching. Three Parts: I: Introduction to Diagnostic Reasoning
II: DR Toolbox
III: Structured Reflection Exercise (SRE)
4 Part I: Introduction to Diagnostic Reasoning Learning Objectives
- Understand the “what” and “why” of Diagnostic Reasoning - Recognize dual-process theory’s role in “how” we reason
6 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 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 Patient’s perspective
What’s wrong with me? Is it bad? What can we do about it?
9 Why now?
Never too early for practice
10 From Novice to Expert
11 How do we reason?
Information processing theory
12 How do we reason?
Information processing theory: Dual process theory.
Analytical Non-analytical Conscious Unconscious Type/System 2 Type/System 1 Slow Fast Effortful Automatic Deliberative Involuntary Logical Emotional Requires attention, Executes skilled self-control, time. response and Hypothesis-driven, generates “intuition” Bayesian (probability) with minimal effort Pattern recognition (illness scripts) Heuristics
13 From Novice to Expert Non-Analytical
Analytical
14 Can you learn/improve diagnostic reasoning?
Nonanalytic Analytic diagnostic reasoning diagnostic reasoning
15 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 Part II: Diagnostic Reasoning Toolbox Learning Objectives
- Review principles for teaching DR to students - Define key terms in teaching DR - Review tips for leading teaching session
18 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 Definitions
Illness script Scheme induction Problem lists
Problem representation/summary statement Framework Differential diagnosis Scaffolds
20 Definitions
Illness script Scheme induction Problem lists
Problem representation/summary statement Framework Differential diagnosis Scaffolds
21 Non-analytical Illness scripts Unconscious Type/System 1 Mental constructs of disease manifestations. Fast “The internal rolodex of diseases.” Automatic Involuntary How we store disease prototype in order to then use it for pattern recognition. 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 Non-analytical Illness scripts Unconscious Type/System 1 Fast Automatic Involuntary Emotional Executes skilled response and generates “intuition” with minimal effort Pattern recognition (illness scripts), Heuristics
23 Definitions
Illness script Scheme induction Problem lists
Problem representation/summary statement Framework Differential diagnosis Scaffolds
24 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 Definitions
Illness script Scheme induction Problem lists
Problem representation/summary statement Framework Differential diagnosis Scaffolds
26 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.
Features of Effective Problem Lists Use precise language Update and modify over time Prioritize Make associations between problems
27 Definitions
Illness script Scheme induction Problem lists
Problem representation/summary statement Framework Differential diagnosis Scaffolds
28 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 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 Definitions
Illness script Scheme induction Problem lists
Problem representation/summary statement Framework Differential diagnosis Scaffolds
31 Framework
A means of building differential diagnoses. NOT patient-specific. Examples: . Worst-First Approach . Mnemonics (e.g., VINDICATE) . Organ System- or Anatomic-based
32 Differential diagnosis
Potential etiologies of a given patient problem.
33 Worst-First Framework
• Ask yourself: Is this life-threatening? Does this patient need to be in an ED?
34 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 VINDICATE (mnemonic Framework)
V Vascular I Infectious N Neoplastic
D Drugs I Inflammatory, Idiopathic C Congenital A Autoimmune/Allergic T Traumatic (including psychological trauma) E Endocrine 36
VINDICATE for CC: Altered Mental Status
Vascular Inflammatory • Stroke (ischemic/ hemorrhagic) • SIRS, vasculitis, pancreatitis, • TIA endocarditis • HTN encephalopathy Congenital Infectious • Epilepsy • Encephalitis • Meningitis Autoimmune • Sepsis • Seizure in lupus patient
Neoplastic Trauma • 1’ or metastatic tumor • Subdural bleed
Drugs/Toxins Endocrine • Overdose/ Withdrawal • Hypo/hyperglycemia • Hypo/hypernatremia • Uremia, ammonia 37 • Hyper/hypothyroid
Organ System or Anatomic-Based Approach
• Define complaint anatomically • If systemic disease, identify specific anatomic involvement • Be thorough
38 Anatomic Approach to Chest Pain
Skin? Muscle? Ribs? Pericardium? Myocardium? Coronary vessels? Pleura? Lung parenchyma? Pulmonary vessels? By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Esophagus? Gray's Anatomy, Plate 492, Public Domain, https://commons.wikimedia.org/w/index.ph p?curid=545522
39 Definitions
Illness script Scheme induction Problem lists
Problem representation/summary statement Framework Differential diagnosis Scaffolds
40 Scaffolds: how to develop students’ reasoning skills.
OLD CARTS
Schema
Problem Lists
SRE
41 Definitions
Illness script Scheme induction Problem lists
Problem representation/summary statement Framework Differential diagnosis Scaffolds
42 Part III: Structured Reflection Exercise (SRE) Learning Objectives
- Review the evidence-based method for assessing diagnostic reasoning
44 ACS
CAD risk factors
30 years old
45 Summary Increase faculty familiarity with diagnostic reasoning principles and tools so as to improve its teaching. Three Parts: I: Introduction to Diagnostic Reasoning
II: DR Toolbox
III: SRE
47 Questions?
Heather Hofmann, MD [email protected] @HeatherNHofmann
48 References
Gordon, D., & Guth, T. (2013). Clinical Reasoning in Medical Students : Retrieved from http://www.cordem.org/files/DOCUMENTLIBRARY/2013 AA/2013 Day Two/Deliberate Metacognition.pdf
Kearney-Strouse, J. (2015). Clinical reasoning now a ‘foundational basic science’ in medical education. ACP Hospitalist. https://acphospitalist.org/archives/2015/11/teaching-clinical-reasoning.htm
Khullar, D., Jha, A. K., & Jena, A. B. (2015). Reducing Diagnostic Errors — Why Now? New England Journal of Medicine, 363(1), 150923140040009. http://doi.org/10.1056/NEJMp1508044
Levin M, Cennimo D, Chen S, Lamba S. Teaching clinical reasoning to medical students: a case-based illness script worksheet approach. MedEdPORTAL Publications. 2016;12:10445.
Modi, J. N., Gupta, P., & Singh, T. (2015). Teaching and Assessing Clinical Reasoning Skills. Indian Pediatrics, 52(9), 787–794. http://doi.org/10.1007/s13312-015-0718-7
Outpatient Diagnostic Errors Affect 1 in 20 U.S. Adults, AHRQ Study Finds. Content last reviewed April 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsroom/press- releases/2014/diagnostic_errors.html
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), 1–7.
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