THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE

Teaching Clinical Reasoning In The

Apprenticeship Model

Nothing

My Thanks Dennis Baker Greg Turner Lynn Romrell

Goals* Stimulate discussion of clinical

reasoning in the context of curriculum redesign

* Share ideas with those who design and implement the 3rd and 4th years of our medical education program.

Objectives1. Describe the role of analytical reasoning

and pattern recognition in clinical decision making.

2. Define cognitive bias and give examples of the mental errors resulting from it.

3. Define framing and give examples of how a physician’s framing of information can lead to an uniformed patient decision

4. Describe strategies the clinical teacher can use to facilitate the learner’s acquisition of clinical reasoning skills

What opportunities do we have?

Consistent with the U.S. national failure pattern, 10% of our 2nd year students in the past 2 years have failed USMLE step 1.

Additional students have trouble with the first or second NBME shelf exams in the third year.

Many of them struggle with OSCE cases that they represent a “mystery” diagnosis.

Even Among Practicing Physicians

Misdiagnosis is common: 15-20% Most of the time (80%) these are

cognitive errors, not knowledge deficits

“Thinking about our thinking as physicians”Jerome Groopman, MD, FACP, and Pamela Hartzband, MD, FACP

What Are We Doing Currently?

CurrMIT data: Clinical reasoning was coded as a

topic in 389 session (lectures, labs, small groups, etc.)

We do not know the amount of time spent on the topic or even if it was a major point of emphasis. We just know the topic was covered.

COURSE SESSIONS

Clinical Anatomy/Embryology/Imaging 36Clinical Microanatomy 17Clinical Neuroscience 34Clinical Physiology 21Doctoring 101 14Doctoring 102 14Doctoring 103 21Doctoring 201 32Doctoring 202 36Doctoring 3 49Health Issues in Medicine 201 1Medical Biochemistry and Genetics 9Medicine and Behavior 201 8Medicine and Behavior 202 4Microbiology 201 11Microbiology 202 11Pathology 201 16Pathology 202 20Pharmacology 201 10Pharmacology 202 25Grand Total 389

How well are our students doing?

To Students You Are a Wizard

How can we help students develop their clinical reasoning skills?

For the Expert ……………

(Benamy, 1996)

For the Learner ………A Developmental Competency

Experience and Deliberate Practice

Deliberate PracticeDoing something wrong repeatedly will not improve the outcome.

Clinical Reasoning DefinitionThe process by which clinicians collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the experience.Hoffman, 2007; Kraischsk & Anthony, 2001; Laurie et al., 2001

Diagnosis Hypothesis generation Context formulation Test interpretation Bayesian reasoning Causal reasoning Differential diagnosis Assessing for adequacy Working diagnosis Cognitive Errors

Clinical Reasoning ConceptsTreatment

Treatment under uncertainty

Risk benefit analysis Treatment thresholds “Toss ups” Therapeutic trial Watchful Waiting

Cognitive Approach To Clinical Reasoning

Analytical (Deliberate) Novice: Does Not Recognize the Pattern Expert: Case Does not Fit the Pattern

Non-Analytical (Pattern Recognition, Intuitive)

Analysis: A Deliberate Approach Principles of logic and hypothesis

testing. Journal Club Start with what we know. Problem solving algorithms.

Head to Toe, Body Systems, Pathophysiology, Acute vs Chronic, Rule out Worst Case Scenario, Exhaustive method, Deductive (Covered in Doctoring 103)Acad Emerg Med: November 2002, Vol 9, No.11

Curriculum for First Two YearsYEAR 1

Doctoring 1 Anatomy Neuroscience Physiology Biochemistry and

Genetics

YEAR 2 Doctoring 2 Microbiology Pharmacology

Pathology Medicine and

Behavior

Constructing a Differential For Syncope

Consciousness requires: Glucose Oxygen Adequate BP and blood flow to

deliver above Organized electrical activity in the

brain Syncope results when any of these

are impaired

Probability Bayesian Theory The predictive value of any

diagnostic test is proportional to the prevalence of the disease in the population tested.

Describes uncertainty when potential outcomes are not equally likely.

As evidence is collected the probability is altered.

About 1 out of every 5,000 people in the US has Marfan Syndrome.

Degree of Certainty Physicians often need to make

decisions with incomplete information

We can always do “one more test.”Odds vs. Stakes (Chest Pain, Rectal

Bleed)Cost vs. Benefit (Unexplained Wt

Loss)Defensive Medicine

Non-Analytical Reasoning

Pattern Recognition Teaching Points

Make the Pattern Fit the Patient, not the Patient Fit the Pattern. (18 month old with lethargy and hyperglycemia)

Don’t stop looking until it fits. Reconcile symptoms (palpitations,

lightheadedness) with findings (EKG, blood glucose)

Avoiding Cognitive Land Mines

Beware! Decisions are not simply a result of logic.

Cognitive Bias Our attempt to Simplify Complexity Simple rules of thumb that lead to

predictably faulty judgments Subconscious mental procedures for

processing information Remains compelling even after one is

aware of itCenter for the Study of Intelligence, CIA, 1999

Examples Aggregate bias Anchoring Ascertainment bias Availability Confirmation bias Fundamental Attribution error

Gambler’s fallacy

Gender bias Hindsight bias

Illusory Omission bias Outcome bias Overconfidence

bias Playing the odds Premature Closure

Representativeness Restraint Visceral bias Zebra retreatAchieving Quality in Clinical Decision Making: Cognitive Strategies and

Detection of Bias by Pat Croskerry, MD, PhD

Overconfidence BiasA willingness to diagnose based on incomplete information when relevant information is available.

Confirmation Bias

The tendency to seek out and assign more significance to evidence that confirms a pattern and ignore or assign much less significance to evidence that does not.

Friendly Fire1994 Iraq No Fly Zone‾ Air Force F-15s‾ Air Force AWAC Plane‾ Army Blackhawk

Helicopters

Snook, Scott A. Friendly Fire: The Accidental Shootdown of U.S. Black Hawks Over Northern Iraq. Princeton, NJ: Princeton University Press, 2000. (Winner of the George R. Terry Book Award, Academy of Management, 2002.)

Army Black Hawk Hind

They saw what they expected

A Patient with Chest Pain

68 year-old male with known coronary artery disease presents with chest pain, nausea and shortness of breath and a complaint of “I’m having another heart attack doc.”

Anchoring Tendency to rely too heavily on one

piece of information when making decisions.

OR Inappropriate reference point

Illusory Bias Causation Association Background Noise

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More Associations Silver Dollars and Umbilical Hernias Antibiotics and viral infections Bed Rest and Premature Labor

A Really Bad Duo Unavoidable Risk Information Cascade

Cognitive Bias Teaching Points

Confirmation: Does everything fit? Illusory: What is the real

relationship? Overconfidence:

Did you find everything? Anchoring, Availability, Attribution:

What else could it be?

Framing Mental model that influences how we

present an issue to others. Influence of risk-aversion on decision

making.

Opportunity or Threat?

Relative or Absolute Risk

Chantix for Smoking Cessation Chantix Representative Long Term (1 year) quit rate with

Chantix is 270% that of placebo Welbutrin Representative

Rate of serious Cardiovascular Events with Chantix was 25% higher than placebo

The Medical Letter on Drugs and Therapeutics • August 22, 2011 (Issue 1371) p.65

Metacognition A method of introspection in which

one is expected to contemplate or reflect on their own thinking to avoid cognitive errors.

A check and balance between intuition and analysis.

Important Points Disease is a movie, you may only

have one scene. Defensive Medicine is not Clinical

Reasoning. How we think, is what we will teach. Let the students hear you

“think out loud”.

Role of Clinical Faculty“The role of the teacher is not to transmit knowledge but to facilitate learning, encourage spontaneity, and engage in mutual inquiry.”“The best time to learn anything is when the material is immediately useful.”“Deliberate Practice”Teaching Clinical Reasoning: Case-Based and Coached Jerome P. Kassirer, MD

Ideal Learning Environment

Multiple Patient Exposures Beginning in the First Year Deliberate Developmental

Progression Learner Driven Expert Mentors

Should we further develop a clinical reasoning curriculum?

What would the developmental progression look like?

Would the Doctoring courses form the backbone?

How do we train/engage the clinical faculty?

Some Questions

References “How Doctors Think”

Jerome Groopman Lecture Series – The Art Of Critical Decision Making

Professor Michael Roberto Lecture Series - What Are the Chances? Probability Made Clear

Michael Starbird, Ph.D. “Thinking about our thinking as physicians” ACP Internist and American College of Physicians, October 2011 Jerome Groopman, MD, FACP and Pamela Hartzband, MD, FACP Wikipedia Google Images