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. 49 .