Facilitation of clinical reasoning during bedside teaching workshop for clinical preceptors

Facilitation of Clinical Reasoning During Bedside Teaching

Workshop For Clinical PreceptorsDr. Muhammed E.M. Elgasim

Educator and Clinical Skills Instructor MBBS EMDM MAcadMEd

Clinical Skills DepartmentSt. George's University

Learning Objectives

• Identify strategies for Clinical Reasoning Strategies

• Identify the RIME Framework for Clinical Competency

• Identify how to facilitate Bedside Teaching (according to Cox Model)

Discussion & Reflection

• How do we interpret the patient data and generate a differential diagnosis ?

• How do we teach out students clinical reasoning ?

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Clinical Reasoning Strategies

Input Output

History

Physical Exam

Accurate Diagnosis

Clinical Reasoning Strategies

1. Pattern Recognition.

2. Hypothesis Testing.

3. Forward Thinking.

1. Pattern RecognitionWhat is the diagnosis ?

2. Hypothesis Testing• 35 year old AA female

with one day history of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, no SOB. Meds: OCPs Normal CV, RS examination except Tachypnea 28 & Tachycardia 130 bpm.

Differential diagnosis 1.CAD2.Pneumonia3.Pericarditis4.PE5.Musculoskeletal6.Pleuritis7.GERD

3. Forward Thinking• 35-year-old African-

American woman with 1-day history of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fever or SOB. Meds: OCPs Normal cardiopulmonary examination except R 28/min & HR 130/min.

• Epidemiology: – Young Women– OCPs

• Temporal course – Acute

• Syndrome (Problem statement)– Pleuritic Chest Pain.– Tachycardia

Illness Script

Expert Organization of Information

Illness script•Demographics (Age, Gender and Race or Ethnicity).•Risk Factors: Other Conditions•Exposers

Epidemiology: who gets it?

•Duration of Prodrome or Symptoms: Hyperacute, Acute, Subacute, Chronic•Pattern of Prodrome or Symptoms: Constant (Stable or worsening), Episodic (Waxing and waning, Biphasic or Interment).

Temporal Course: How does this disease present with respect to time?

•What are the known derangements in: Anatomy, Physiology, Immunology, Biochemical pathways, Genetics, and Metabolomics.

•What are known environmental contributors: Microbiology, Toxins, and Pharmacology.

Pathophysiology: What are the biomedical causes of this disease?

•Key and Differentiating Features ± MUST HAVE & REJECTING Features.

Clinical presentation (Syndrome Statement)

Maturation of clinical reasoning

Novice Expert

Data Gathering

Diagnostic accuracy

Forward Thinking + Pattern

Recognition

Hypothesis Testing

Clinical Knowledge Organization

Student's Clinical Knowledge Organization

• 35-year-old African-American woman with 1-day history of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fever or SOB. Meds: OCPs Normal cardiopulmonary examination except R 28/min & HR 130/min.

Spontaneous Pneumothorax

Psychiatric

Pulmonary embolism

Pneumonia

Expert's Clinical Knowledge Organization

From Catherine R. Lucey, MD Clinical Problem Solving https://www.coursera.org/course/clinprobsolv

Teaching Forward Thinking

SymptomsInvolved System(s)

More Symptoms, Exposure or Risk factors

Involved system(s)

SignsInvolved system(s)

List of Symptoms and signs

Forward Thinking

Illness Script

CC & HPI

Discussion & Reflection

• How do we assess our trainee competency ?

• How do we communicate that assessment with our trainee?

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Clinical Competency Framework

Watch the following videohttps://www.youtube.com/

watch?v=ifTAzAiTPQY

Answer the following questions

• What does the trainee demonstrate for each RIME Level?

• What types of questions that trainee can answer for each RIME Level?

PICTURE From https://www.haikudeck.com/copy-of-rime-framework-for-medical-education-education-presentation-46d262fe5a#

RIME Clinical Competency Framework

• R.I.M.E Model – Describes performance goals for trainees.– Apply to single encounter or to overall

performance .

From Sally Santen M.D., Ph.D: Teaching and Assessing Clinical Skills https://www.coursera.org/course/clinicalskills

Reporter

Answers “what” questions

Interpreter

Answers “why” questions

Manager

Answers “how” questions

Educator

Learner Maturation

NoviceReporter

ExpertEducator

Data Gathering

Diagnostic accuracy

Discussion & Reflection

• How do you plan and conduct your bedside teaching ?

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Cox Model for Bedside Teaching

The Learning Triad (and its environment)

Clinical Bedside Teaching: Challenges

• Teacher related challenges .

• Patient related challenges .

• Student related challenges .

• Environmental challenges .

Prepare The Teacher

• Prepare The Teacher – Consider the “six domains of knowledge”

1. Medicine2. Patients3. Context4. Learners5. General principles of teaching6. Case-based teaching scripts

• Prepare The patient.

• Prepare The student.

Cox Model for Bedside Teaching

From John Dent et al; Getting Started In The Hospital Ward, Dundee.

The Experience Cycle

The Explanation Cycle

Models of Bedside Teaching

• Demonstrator model

• Facilitator model

• Observer model

DEMONSTRATOR MODEL

Patient

Clinician/Tutor Student

FACILITATOR MODEL

Patient

Clinician/Tutor Student

OBSERVER MODEL

Patient

Clinician/Tutor Student

When the session is over?

• Preceptor and students need a framework or structure to focus the outcomes of the teaching session.

• Acronym EPITOMISE links to the major learning outcomes.

ES

IM

OT

I

PE

Enquiry (communication and ethics)Physical examinationInvestigations and interpretations of resultsTechnical proceduresOptions of diagnosisManagementInformation handlingSciences – basic / clinicalEducation of the patients and yourself

Picture From John Dent et al; Getting Started In The Hospital Ward, Dundee.

Summary

• Strategies for clinical reasoning strategies.

• The RIME framework for clinical competency.

• Facilitation bedside teaching (according to COX model).

Any Questions

References • John Dent et al; Getting Started In The Hospital Ward, Dundee. • John Dent; A Practical Guide for Medical Teachers, 4th edition.• Robert L et al; Teaching Clinical Reasoning (Teaching Medicine

Series) American College of Physicians. Kindle Edition. • Mary Seabrook; How to Teach in Clinical Settings, Wiley.• Jeff Wiese; Teaching in the Hospital (Teaching Medicine Series)

American College of Physicians. • From Catherine R. Lucey, MD Clinical Problem Solving

https://www.coursera.org/course/clinprobsolv• From Sally Santen M.D., Ph.D: Teaching and Assessing Clinical

Skills https://www.coursera.org/course/clinicalskills