“ We’re pretty sure it’s the West Nile virus.”

“We’re pretty sure it’s the West Nile virus.”

Assessment of Diagnostic Reasoning and Clinical

ThoughtChart Stimulated Recall

Clinical Judgment/Reasoning

The cognitive engine that drives problem-solving and decision-making.

www.chinesenursing.org/openAccess/sn331/html/doc/cyber-M1_students.pdf clinical reasoning definition

Critical Thinking Good Thinking

– Sensitivity• Interest in gaining

more information• Seeking alternatives

– Inclination• Willing to invest

energy in thinking the matter through

– Ability• Possess the

cognitive ability

“Bad Thinking” – “cognitive misers”– Chose to take mental

shortcuts, engage in heuristic thinking,

– without interest in “good thinking”

Krupat 2011

Clinical Judgment/Reasoning

Internal process Trainees and faculty need ways to

externalize this process Programs need to identify assessment

methods that document growth and competency in this skill

Key Elements of Diagnostic Reasoning

Patient’s story

Data acquisition

Accurate “problem representation”

Generation of hypothesis

Search for and selection - illness script

Diagnosis

Knowledge

Context

Experience

Bowen JL. NEJM; 2006: 2217

Clinical Reasoning

Graber¹ adverse event study:– Most errors combination of individual and systems

factors– Average 5.9 system +/- cognitive error per case

“Cognitive factors”:– 320 cognitive factors in 74 cases– 45 due to faulty data gathering– 264 due to faulty synthesis (problem representation)

¹ Arch Intern Med. 2005; 165: 1493.

Problem Representation

Non- analytical - The behavior of experts– Pattern Recognition illness scripts

– Heuristics• The rapid non-analytic mental shortcuts that

humans use to recognize and categorize things.

Analytical - The work of early learners– Hypothesis based deductive reasoning

– The default when a pattern is not apparent

Clinical presentation

No clearPattern

Pattern identified

Hypothesis basedDeductive reasoning

(Analytic)

Illness scriptSelected

(Non-analytic)

You evaluate a 78-year-old male with a 2-week history of joint pain beginning after

cardiac catheterization. Both knees and one wrist are red, painful, and swollen. X-ray is

pending. No fever, weight loss or malaise, and recent

labs reveal an ESR of 50. Past medical history includes CAD and hypothyroidism.

Processed Problem Representation

78-year-old (ELDERLY) male for evaluation of a 2-week (SUBACUTE) history joint pain. Symptoms began 1 week after a cardiac catheterization (RECENT MEDICAL INTERVENTION). Both knees and one wrist

(OLIGO-ARTICULAR). He has no fever, weight loss, or malaise (NON-SYSTEMIC).

Recent labs are significant for an ESR of 50 (INFLAMMATORY).

Pattern – illness script

ElderlySubacuteRecent medical

interventionOligoarticularNon-systemic Inflammatory

Pseudogout

Heuristics Availability

– Diagnose disease that are familiar or striking • HTN is due to pheochromocytoma

Recency– Diagnosis is proposed because it was recently seen

• I just read about ----

Anchoring– Weight data that supports your diagnosis more than

data that does not

The Art of Clinical Questioning

Promoting/Probing Clinical Reasoning

– Minimize overuse of recall questions

– Use compare and contrast learning

– Avoid “what am I thinking now?”

– Encourage identification of key features of an illness

Chart-Stimulated Recall

Uses the medical record as a reference point for structured clinical questioning

Specifically targets clinical reasoning Developed by the ABEM High correlation between examiners Reliable enough with 3 cases for pass/fail

determinations Ultimately dropped by ABEM because of cost

and time requirement

Chart Stimulated Recall

Requirements:– Conducted by medical faculty– Faculty development needed– Ideally, the medical record is reviewed

in advance to identify specific questions

Chart Stimulated Recall

Benefits

– Inexpensive and easy to teach

– Uses patients/clinical scenarios familiar to the trainee (context of care)

– Allows examiner to assess problem solving and interpretation skills

– Adaptable to multiple learner levels

Small Group Exercise

Review this resident note. The resident is on a one month

geriatric rotation. Are there opportunities to explore

the resident’s diagnostic reasoning?

Questioning Recall

– What, how, why?• What is the significance of dip stick positive hematuria in

the absence of RBCs? Analysis/synthesis

– Demonstrate reasoning• There are multiple causes for falls in the elderly, what

features of this presentation suggest volume loss/anemia as opposed to drug side effect?

Application– Apply knowledge/skills/attitudes to a specific presentation

• In the setting of renal insufficiency with a history of diabetes, new NSAID use, and and polymyosiitis, how would you distinguish determine etiology?

Overall Note:Clarity____________________________________Organization ____________________________________Documentation____________________________________Internal Consistency - Identify any disconnects in the history and physical.

Based upon the history and physical?

Are you comfortable responding to a change in clinical status

Appropriate incorporation of labs in diagnosis and plan

Documented thought process for treatment plan

Treatment appropriate for diagnosis

Documented thought process for differential diagnosis

Accurate differential diagnosis

Appropriate analysis of lab data

Appropriate Physical

Appropriate History

Delineation of sick vs non sick

Clear Chief Complaint

N/ANOYESPlease check ONLY ONE box per statement

Based upon the history and physical?

Are you comfortable responding to a change in clinical status

Appropriate incorporation of labs in diagnosis and plan

Documented thought process for treatment plan

Treatment appropriate for diagnosis

Documented thought process for differential diagnosis

Accurate differential diagnosis

Appropriate analysis of lab data

Appropriate Physical

Appropriate History

Delineation of sick vs non sick

Clear Chief Complaint

N/ANOYESPlease check ONLY ONE box per statement

Night Float CSR

0

1

2

3

4

5

6

7

8

9

10

Score

Jul Au Se Oc No De Ja Fe

Academic Month

Table 3 Resuls of Random History and Physical Review

How might your program utilize a

CSR exercise?

Donobedian Framework

Schematic representation of a system Every system has a structure and a process

that processes that produce an outcome

S + P = O You need to consider each of these

components in your assessment system!

Donobedian Framework

S + P = O

Night float MR + CSR = Evaluation of trainee clinical thought/diagnostic reasoning and a documented educational experience on night float rotation

Questions