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

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

Nov 10, 2023 36 likes •201 views

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

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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

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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

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Educational Strategies to Promote Clinical Reasoning

Bowen, J. N Engl J Med 2006;355:221-25

History Data acquisition “Problem representation” Hypothesis generation “Illness script” (search/ select) Diagnosis

Knowledge Context Experience

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

  • rthopedic procedure.

Bowen, J. N Engl J Med 2006;355:221-5

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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?

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System 1 Intuitive System 2 Analytic

Dual Process Theory Dual Process Theory

System 1 - Intuitive Implicit Experiential Automatic Pattern recognition Matching against illness scripts System 2 - Analytic Analytic Deliberate Rational

Careful analysis Wide differential

Acad Med. 2009; 84:1022-28.

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Dual Process Theory

System 1 - Intuitive 26-year-old woman, with unilateral LE edema after an 18=-hr transcontinental flight. She is on oral contraceptives. Differential Diagnosis?

  • 1. DVT
  • 2. DVT
  • 3. DVT

Dual Process Theory

System 2 - Analytic 54-year-old man with AIDS, CD4 =40, presents with fever, pancytopenia, headache,

  • dynophagia, and a

maculopapular skin

  • rash. He recently

traveled to Southeast Asia, backpacking. Differential Diagnosis?

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System 1 Intuitive System 2 Analytic

Dual Process Theory

Experts vs. Novices Heuristics “Slowing down 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

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  • 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

Classic Heuristics that may Lead to Errors

  • 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”

Availability Heuristic

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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?

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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
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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

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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

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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

– Use framework – “Think out loud”

History Data acquisition “Problem representation” Hypothesis generation “Illness script” (search/ select) Diagnosis

Knowledge Context Experience

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http://www.uab.edu/medicine/gim/fellowship

  • 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

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/

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DOWNLOAD SLIDES NOW: https://sites.google.com/site/sgimhandouts/

Tinsley Harrison Internal Medicine Residency Program Birmingham Veterans Affairs Medical Center

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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/