Learning Objectives Recognize dual-process decision making (System - PDF document

3/24/2013 How Doctors Think: Clinical Problem Solving in Action Carlos Estrada, MD, MS, Robert M. Centor, MD, Jason Morris, MD, Ryan Kraemer, MD, Amanda Vick, MD, Lisa Willett, MD, Starr Steinhilber, MD, MPH Tinsley Harrison Internal Medicine Residency Program University of Alabama at Birmingham Chad Miller, MD, Deepa Bhatnagar, MD Tulane University Jeff Kohlwes, MD,MPH University of California at San Francisco DOWNLOAD SLIDES NOW: https://sites.google.com/site/sgimhandouts/ Learning Objectives • Recognize dual-process decision making (System 1, 2) and heuristics • Identify educational strategies to promote clinical reasoning 1

3/24/2013 Agenda • Introductions … 5 min • Clinical reasoning … 15 min • Large group exercise … 20 min • Small group exercise … 20 min • Conclusions … 10 min • Evaluation … 5 min Clinical Reasoning 2

3/24/2013 Educational Strategies to Promote Clinical Reasoning Bowen, J. N Engl J Med 2006;355:221-25 History Knowledge Data acquisition “Problem representation” Context Hypothesis generation Experience “Illness script” (search/ select) Diagnosis Clinical Reasoning • Problem representation: one sentence summary defining the specific case in abstract terms A middle age man with sudden onset pleuritic chest pain, shortness of breath, and hemoptysis after an orthopedic procedure. Bowen, J. N Engl J Med 2006;355:221-5 3

3/24/2013 Clinical Reasoning • Illness script: A summary of a diagnosis including predisposing factors, pathophysiology, clinical findings Pulmonary thromboembolism: post-orthopedic procedure, compression/ stasis, LE venous thrombosis, pulmonary infarct, dyspnea, tachypnea ,… Bowen, J. N Engl J Med 2006;355:221-5 How Do Doctors Think? Fast or Slow? 4

3/24/2013 Dual Process Theory System 2 System 1 Analytic Intuitive Dual Process Theory System 1 - Intuitive System 2 - Analytic Implicit Analytic Experiential Deliberate Automatic Rational Pattern recognition Careful analysis Matching against Wide differential illness scripts Acad Med. 2009; 84:1022-28. 5

3/24/2013 Dual Process Theory System 1 - Intuitive Differential Diagnosis? 26-year-old woman, with unilateral LE edema after an 18=-hr 1. DVT transcontinental flight. 2. DVT She is on oral 3. DVT contraceptives. Dual Process Theory System 2 - Analytic Differential Diagnosis? 54-year-old man with AIDS, CD4 =40, presents with fever, pancytopenia, headache, odynophagia, and a maculopapular skin rash. He recently traveled to Southeast Asia, backpacking. 6

3/24/2013 Dual Process Theory Experts vs. Novices Heuristics System 2 System 1 “Slowing down Analytic Intuitive when you should” Naturalistic Decision Making Heuristics • Rules of thumb, mental shortcuts or simple decision making strategies – A young man with cachexia, prior Hx of IV drug use, oral thrush  Think HIV/ AIDS http://en.wikipedia.org/wiki/Heuristics_in_judgment_and_decision_making 7

3/24/2013 Classic Heuristics that may Lead to Errors • Anchoring heuristic – focusing too much on 1 piece of information • Availability heuristic – influenced by the last patient you saw, memorable patient • Premature closure - related to anchoring heuristic Availability Heuristic • 30-year-old man, fever, maculopapular rash, camping in the Rockies (early winter) • “I just saw pictures on a patient with human monocytic anaplasmosis (HMA), … this could be HMA” 8

3/24/2013 How Do You Teach Clinical Reasoning? Large Group Exercise Discussant - Presenter Audience: What is the problem representation? Observe any illness scripts? Is System 1 or 2 used? Observe any heuristics? 9

3/24/2013 Debrief Audience: What is the problem representation? Observe any illness scripts? Is System 1 or 2 used? Observe any heuristics? Small Group Exercise • Select: A: chorea, B: dyspnea, C: anxiety • Read: Presentation, clinical discussion • Task: Discuss clinical reasoning »Problem representation, illness scripts »System 1 or 2, heuristics • Debrief: Assign a reporter 10

3/24/2013 Small Group Exercise A. A 60-Year-Old Woman with Chorea and Weight Loss (Vick . JGIM 2012;27:747-751) B. A Middle-Age Woman with Sudden Onset Dyspnea (Bhatnagar. JGIM 2011;26:551-4) C. A 76-year-old woman with diaphoresis and anxiety ( Steinhilber et al – under review ) Small Group Exercise - Debrief • Clinical reasoning – Problem representation – Illness scripts – System 1 or 2 – Heuristics 11

3/24/2013 Conclusions Teaching Clinical Reasoning • Clinical Problem Solving – Monthly, 3 unknown cases, teaching pearls • Tinsley Harrison Morning Report – Weekly, 1 unknown case presented to a group of specialists (internists, others), teaching pearls • International Rounds – Monthly, 2 unknown cases presented by one site, discussed by other site (Peru, UAB) Tinsley Harrison Internal Medicine Residency Program University of Alabama at Birmingham 12

3/24/2013 Metacognition Strategies # 1: What else could this be? # 2: Is there something that does not fit? # 3: Is there more than one diagnosis? Groopman J, Hartzband P. Thinking about our thinking as physicians. ACP Internist 2011, October. http://www.acpinternist.org/archives/2011/10/mindful.htm Take Home Points • Dual-process decision making – System 1: intuitive – System 2: analytic • Promote clinical reasoning History – Use framework Knowledge Data acquisition “Problem representation” Context – “Think out loud” Hypothesis generation Experience “Illness script” (search/ select) Diagnosis 13

3/24/2013 • VA Chief Medical Resident in Quality and Safety (CMRQS). One-year position (PGY4). Integration of quality and safety concepts into the fabric of residency training programs as well as developing expertise in milestones development for System Based Practice and Problem Based Learning and Improvement. • VA Quality Scholars Fellowship (VAQS). A two-year position for residents, fellows, or practicing clinicians from any medical or surgical specialty (MD). Time to obtain MSPH or equivalent degree provided. Positions for pre and post doctoral nursing are also available. Carlos Estrada MD, MS, cestrada@uab.edu, VAQS Director Gustavo Heudebert, MD, gustavo@uab.edu, VA CMRQS Director http://www.uab.edu/medicine/gim/fellowship References 1. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006;355:2217-25. 2. Croskerry P. A universal model for diagnostic reasoning. Acad Med. 2009; 84:1022-28. 3. Vick A, Kraemer RR, Morris JL, Willett LL, Centor RM, Estrada CA, Rodriguez JM. A 60- Year-Old Woman with Chorea and Weight Loss. J Gen Intern Med. 2012;27:747-751. 4. Bhatnagar D, Morris JL, Rodriguez M, Centor RM, Estrada CA, Willett LL. A Middle-Age Woman with Sudden Onset Dyspnea. J Gen Intern Med. 2011;26:551-4. 5. Roy B, Castiglioni A, Kraemer RR, Salanitro AH, Willett LL, Shewchuk RM, Qu H, Heudebert G, Centor RM. Using Cognitive Mapping to Define Key Domains for Successful Attending Rounds. J Gen Intern Med. 2012;27:1492-8. 6. Henderson MC, Dhaliwal G, Jones SR, Culbertson C, Bowen JL. Doing what comes naturally. J Gen Intern Med. 2010;25(1):84-7. 7. Moulton CA, Regehr G, Mylopoulos M, MacRae HM. Slowing down when you should: a new model of expert judgment. Acad Med. 2007;82(10 Suppl):S109-16. 8. Kassirer JP. Teaching clinical reasoning: case-based and coached. Acad Med. 2010;85(7):1118-24. 9. Norman G. Diagnostic errors and dual processing. Adv Health Sci Educ Theory Pract. 2009. Suppl 1:37-49. 10. Coursera – Clinical Problem solving https://www.coursera.org/course/clinprobsolv DOWNLOAD SLIDES NOW: https://sites.google.com/site/sgimhandouts/ 14

3/24/2013 DOWNLOAD SLIDES NOW: https://sites.google.com/site/sgimhandouts/ Tinsley Harrison Internal Medicine Residency Program Birmingham Veterans Affairs Medical Center 15

3/24/2013 How Doctors Think: Clinical Problem Solving in Action Carlos Estrada, MD, MS Jason Morris, MD Ryan Kraemer, MD Starr Steinhilber, MD, MPH Amanda Vick, MD Tinsley Harrison Internal Medicine Residency Program Chad Miller, MD Deepa Bhatnagar, MD Tulane University DOWNLOAD SLIDES NOW: https://sites.google.com/site/sgimhandouts/ 16