Lessons Learned from Remediation of Clinical Reasoning: Identifying - - PowerPoint PPT Presentation

Lessons Learned from Remediation

• f Clinical Reasoning:

Identifying Deficits and Teaching in Real Time

Andrew S Parsons, MD, MPH Karen M Warburton, MD

Outline

• 3 case vignettes
• Clinical reasoning as a concept
• Clinical reasoning deficits in graduate medical education
• Our approach to remediating clinical reasoning at UVA
• Applying the lessons learned from remediation to every day teaching

Case 1 – PGY2

• Trouble managing a patient list
• Handoffs are ineffective
• Seems to lack “the big picture” with patients
• As an intern, presentations were “a bit all over the place,” struggled

to communicate effectively when calling consults

• As a medical student, comments suggest that “presentations

improved over the course of the rotation”

Case 2 – PGY2

• Easily overwhelmed and seems disorganized
• Not responding appropriately to urgent situations
• MET call – needs a lot of supervision
• MICU attending concerned that prioritization of issues during presentations

does not reflect recognition of urgency, sick versus not sick

• Can’t triage her “to do” list
• Seems to “miss the forest for the trees”

Case 3 – PGY3

• Extremely detail oriented
• Presents expansive differential diagnosis lists even after diagnosis is relatively certain
• Orders expensive/invasive imaging and procedures, labs multiple times per

day on all patients, long antibiotics courses

• Uncomfortable with discharge
• Focused on “worst case scenario”
• As a medical student, Honors core clerkships

What do all of these learners have in common?

KNOWLEDGE

KNOWLEDGE (Content and Process)

Bowen JL. N Engl J Med. 2006;355:2217-25; Balogh et al., Improving Diagnosis in Health Care.

“A complex patient-centered cyclical process of information gathering, information integration and interpretation, and forming a working diagnosis. This process involves hypothesis generation and updating prior probabilities as new information is learned. As the diagnostic process proceeds, a broad list of potential diagnoses may be narrowed into fewer potential options. Throughout the process, there is an

• ngoing assessment of whether sufficient information has

been collected. The end goal is not certainty, but a reduction in diagnostic uncertainty sufficient enough to make optimal decisions about management/treatment.”

Schmidt HG. Med Educ 2015; Custers EJ. Med Teach 2015

Knowledge is necessary but…

Physiology Pathophysiology Disease (signs and symptoms)

Goal: Causal Understanding (Content)

Disparate Biomedical Facts Organize and Manipulate Biomedical Facts Diagnosis

Goal: Categorization (Process)

Foundational Pillars of Teaching Decision-Making

• Dual Process Theory
• Problem Representation
• Illness Script

Clinical Problem Information Processing Pattern Recognition (illness scripts, heuristics) Analytic (logical thinking) Fast Slow Diagnosis stimulus to switch

toggle

Croskerry P. Acad Med. 2009; 84:1022-28.

Dual Process Theory

Problem Representation

• A fluid concise summary that highlights the defining features of a

case, helping clinicians generate a focused differential diagnosis.

• Develops context (framing)
• Prompts illness scripts

Evolves during a clinical encounter to answer 3 Q’s: a) Who is the patient? (demographics and risk factors) b) What is the temporal pattern of illness? (use semantic qualifiers) c) What is the key signs and symptoms? (combine key features)

Bowen JL. N Engl J Med. 2006

PRIORITIZED DIFFERENTIAL DIAGNOSIS

(FRAMING)

Illness Script

• Duration and Pattern of

Sx (acute, chronic, constant, waxing and waning…)

• Key differentiating

features

• Anatomy, physiology,

biochemistry, pathology, immunology, pharmacology, etc.

• Demographics, risk

factors, exposures

Epidemiology Mechanisms Time Course Clinical Presentation

A mental representation

• f a disease, stored in
• LTM. Repeated

exposures to different presentations of the same disease (or CC) allow clinicians to link distinguishing features and recognize patterns, elaborating on prior scripts or creating new

• nes. Scripts are handled

in working memory as a chunk.

K Gavinski, et al. Acad Med. 2019

Novice Expert Working Memory Capacity 7 + 2 Items or “chunks” Scripts

Developing Expertise

• The # and variability of illness scripts stored in long term memory
• The richness of the coding and retrieval networks to access scripts when they are needed

Cutrer WB, Acad Med 2017

Hypothesis Generation Data Gathering Problem Representation Refine Hypotheses Working Diagnosis

Putting it all Together

Parsons A, Clancy C, Rencic J, Warburton KM. Under review for publication

Clinical reasoning deficits among medical trainees

• GME remediation data reported in surveys and single-center

reviews

• Not an ACGME competency, so data not captured in surveys
• Probably often “misdiagnosed”
• Medical knowledge, organization, communication, professionalism
• University of Colorado
• 25-30% of residents, and 40-45% of medical students, referred to a

remediation program

• University of Pennsylvania
• 40-45% of learners referred to a combined UME-GME remediation

program

Warburton KM, Shahane, AS. ACGME 2019, NEGEA 2019

UVA COACH

UVA COACH Data, 2016-current

• 65 referrals
• 49 residents
• 16 fellows
• 15 departments
• 1/3 self referrals

Unpublished data

Coachi hing C Clini nical al R Reas asoni ning: A Remediati tion

• n P

Program

COACH Clinical R Reasoning S Subcommittee February 13, 13, 201 2019

CR Coaching Program at UVA

• Lead Coach – Andrew Parsons, MD, MPH
• Clinical Reasoning Subcommittee of COACH
• 11 faculty members from 8 departments
• Mission

1. Train members in a standardized approach to the diagnosis and coaching of clinical reasoning deficits among graduate medical learners 2. Develop durable materials that a variety of academic departments at UVA can use for coaching

Hypothesis Generation Data Gathering Problem Representation Refine Hypotheses Working Diagnosis

Diagnose the deficit

Hypothesis Generation Data Gathering Problem Representation Refine Hypotheses Working Diagnosis

Think Base Rate:

Categorize initial differential in terms of common, atypical, rare, and “can’t miss” diagnoses

Highlighter:

Identify key clinical features in a written H&P based on possible diagnoses

Scaffolding:

Start with chief complaint and demographics, use an analytic approach (anatomic, pathophysiology, or systems- based schema or mnemonics) to craft broad differential

Priming for Co-Selection:

Outline differential based on chief complaint alone; propose three diagnoses followed by five questions and five exam findings to promote hypothesis-driven reasoning

Articulated Problem Representation:

Use key features and semantic qualifiers to craft a 1-2 sentence case summary

Reverse Presentation:

Start presentation with assessment to prime for feedback on selection and

• rganization of subjective

and objective data

Findings that Matter:

Identify findings that have the biggest impact on increasing

• r decreasing the

probability of diagnoses

Structured Reflection:

List aspects of patient presentation that are concordant, discordant, and expected but missing for leading diagnoses

The Eyes Have It:

Practice visual diagnosis to enhance pattern recognition

Persuade the MD:

Assuming the role of a patient, learner describes how they would convince a physician of a specific diagnosis

Then treat…

Parsons A, Clancy C, Rencic J, Warburton KM. Under review for publication

Remember Case 1

• PGY2
• Trouble managing a patient list
• Handoffs are ineffective
• Seems to lack “the big picture” with patients
• Intern presentations were “a bit all over the place”
• Struggles calling consults

Hypothesis Generation Data Gathering Problem Representation Refine Hypotheses Working Diagnosis

Diagnosis the deficit

Clue: multiple forms of communication (presentation, handoffs/sign-out, calling consults) lack clear, concise information Dx: Data gathering and/or problem representation Tx: Highlighter, priming for co-selection, articulated problem representation, reverse presentation

Remember Case 2

• PGY2
• Easily overwhelmed and seems disorganized
• Not responding appropriately to urgent situations
• MET call – needs a lot of supervision
• MICU concerned cannot identify “sick versus not sick”
• Can’t triage her “to do” list
• Seems to “miss the forest for the trees”

Hypothesis Generation Data Gathering Problem Representation Refine Hypotheses Working Diagnosis

Diagnosis the deficit

Clue: Struggles with urgency/triage Dx: Could be any/all. Hypothesis generation? Tx: Standardized framework, prioritized to-do list, forest checklist

Remember Case 3

• PGY3
• Extremely detail oriented, presents expansive Ddx

lists even after diagnosis is relatively certain

• Known for ordering expensive/invasive imaging and

procedures, labs multiple times per day on all patients, long abx courses

• Uncomfortable with discharge
• Focused on “worst case scenario”
• As a medical student, honors core clerkships

Hypothesis Generation Data Gathering Problem Representation Refine Hypotheses Working Diagnosis

Diagnosis the deficit

Clue: Silo/frozen Ddx, overtesting, overtreatment, low tolerance for uncertainty Dx: Refine hypotheses, working diagnosis Tx: Persuade the MD, structured reflection

Structured Reflection

• Best evidence supports use of

structured reflection to determine assessment of fit

• List aspects of presentation that are

concordant with diagnosis.

• List aspects of presentation that are

discordant with diagnosis.

• List aspects you would expect, given

the diagnosis, but are missing from the presentation

Mamede et al. Acad Med 2014

Applying the lessons learned from remediation to everyday teaching

Lessons Learned from Remediation

• Correct “diagnosis” is critical and requires a systematic assessment

process

• This requires direct observation, to which there are many barriers
• Competency-based categorization of deficits is not that useful for designing

remediation plans

• The mentor/coach must empower the learner to guide their

experience

“Needs to read more” “Needs to expand knowledge” “Disorganized, inefficient”

Most Common Learner Chief Complaints

Usually a signal that something is wrong… …but it’s often not knowledge

Clues that it’s actually a clinical reasoning deficit

• Difficulty with patient presentations
• Can’t see the forest for the trees
• Can’t summarize patient in a succinct 1 line
• Orders too many tests
• Can’t create or prioritize a differential diagnosis
• Can’t structure an admission or clinic visit efficiently
• Can’t triage a task list, recognize urgency, discern sick v not sick
• Common cognitive biases
• Anchoring (premature closure)

Barriers to Direct Observation

Lessons Learned from Remediation

• Correct “diagnosis” is critical and requires a systematic assessment

process

• This requires direct observation, to which there are many barriers
• Competency-based categorization of deficits is not that useful for designing

remediation plans

• The mentor/coach must empower the learner to guide their

experience

A process in which individuals take the initiative, with or without the help of

• thers, in diagnosing their learning needs,

formulating goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning

• utcomes

Knowles M. Self-Directed Learning: A Guide for Learners and Teachers. New York, NY: Associated Press; 1975

Self-Directed Learning

In conclusion

• Clinical reasoning, while not an ACGME competency, is a common

area of struggle among graduate medical learners and requires a targeted approach for diagnosis and treatment

• The remediation process highlights several important aspects of adult

learning theory that faculty can incorporate into every day teaching in the clinical learning environment

Questions?