AnticipatinAnticipatin& Interpreting Ph

A Hypothesis-Driv

Georg

J. RDM

J. OH. N

University of Pittsburgh S20

g Elicitingg, Elicitinghysical Findingsen Physical Exam

ges BORDAGE, MD, PhD

R. YUDKOWSKY, MD, MHPERIDDLE, MD & T. LOWENSTEIN, MD

ME, University of Illinois at ChicagoTAKI, MD, PhD Tokyo Medical Univ.

NISHIGORI, MD University of Tokyo

School of Medicine, April, 09

“Screening” HScreening H

140 maneuver(Still ti(Stillman consortium

Checklist driven

Head-to-toe PEHead to toe PE

rs for healthy pts‘80 )m, ‘80s)

exercise

2

“What are you thinkin

“Oh, I haven’t starteFi t I th ll thFirst I gather all theI think about it.”

ng?”

ed thinking yet.d t d the data and then

“Screening” HScreening H

Mechanical thoro Rote exercise Rote exercise Out of contextOut of context

…not linked to pt(C t t V d V & S(Contrary to Van der V. & Sintegrated into clinical stud

St d t t thi Students not thin

Head-to-toe PEHead to toe PE

oughness

t complaintsSh i th (2005)Shurwirth (2005)dies)

ki4

nking

Csqs during Csqs during

Diffi lt to Difficulty to:- Select relevan- Recognize abn- Interpret whap

Checklist thorough

Context & thinCo te t & t

clerkships… clerkships…

nt maneuvers/signsnormal findingsat they findy

hness is not enough

nking5

g

HypothesisHypothesisIn context ofIn context of

Anticipate : DisAnticipate : Dis

Elicit signs : Cor

Interpret : Ana

B t d I Be corrected : Im

Document : RepDocument : Rep

s-driven PEs-driven PEHx + Diff DxHx + Diff. Dx

scriminating findingsscriminating findings

rrect maneuvers

alytical thinking

di t f db kmediate feedback

porting accuracy6

porting accuracy

PresentationPresentation

1. Rationale for H2. Case developm3. Student PE asse4 I i i l lidi fi4. Initial validity fi

R&D project

nn…

DPEentessmenti diindings

7t in progress...

This project was funded

This project does not neceand NBME support providand NBME support provid

Aid for ScientiAid for ScientiMin. of Ed., Culture, Spo

Government of Jap

d in part by grants from:

cessarily reflect NBME policy des no official endorsementdes no official endorsement.

ific Researchific Researchorts & Science & Techno.pan, Tokyo, Japan

Ratio(4 i(4 main

Have a Dx in mind Sort out a Sort out a

differential dx(anal tical easoning)(analytical reasoning)

Create solidfoundation

Transfer into Transfer into practice

onalesfi di )findings) Bordage, 1999

See more findings Looking for Looking for

discriminating featuresfeatures

Less is more(prototypes)

Mixed practice9

Mixed practicewith feedback

Data gag0.8 Dx

0.6

0.7PhEx

0.4

0.5

0 2

0.3

0.4

0.1

0.2 Brief CC

0

atheringg

Features arex

Features are more evident when Dx iswhen Dx is also available

You seewhat you’rewhat you relooking for...Norman, 1996, 2000Hatala, 1999

Feature ideFeature ide- an interactiv

If looking right DxIf l ki thiIf looking somethingJust looking thoroughJust looking, thorough

If looking wrong Dx

entificationentificationve process -

Physical signs

Most ++++M(DDx) Many +++

h: Fewer +/-h: Fewer +/Least --

…avoid collectingsimply for its owfor being thorougfor being thoroug

Have a Dx in mYou will see m

g datan sake,ghgh

mind.ore…

How many DHow many D

SAll 34 cau

vs.4 protp

e.g.rota

Dx initially ?Dx initially ?

houlder painuses in Jacob’s Textbook

totypical causesyp, tendonitis, capsulitis,

ator cuff, referred pain

13

, p

How many DHow many D

r = -.N b di dNumber disorderPrototype formaPrototype forma

(anchor points)

less is mo…less is mo

Dx initially?Dx initially?Bordage, 1987

58/ trs/ syst. course

tion in memorytion in memory )

ore14

ore

PneumoniaPneumonia& typhoid

“if thoroughlyunderstood bythe students, [they] give tthe students, [they] give ta satisfactory foundationwhich to build their laterwhich to build their laterexperience.” - 192

“… the studenttries to learn tootries to learn toomuch, and wethe teachers tryto teach too much– neither, perhaps,with great success”them with great success

- 1899 -themn on

Wm. Osler925 -

140 PhEx m140 PhEx m

19 chief com

l 3-4 prototypical, co

Findings for each Dx Findings for each Dx

Devel. Drs. Otaki, Nishogo

~60 Dx as a solid~60 Dx as a solid

maneuversmaneuvers

plaints (23 CC ≈ 80%)

d /mpeting diagnoses/ CC

x (Evidence b : sensit spec )x (Evidence-b.: sensit., spec.)

ori & Bordage in Japan

foundation16

foundation

ShouldShould

4 diagnoses: Bicipital tendonitis Adhesive capsulitis Adhesive capsulitis Rot. cuff tendonitis Referred pain

der painder pain

1616 maneuvers:Point to areaFlexionInt. & external rotationNeck flexion & extensionL & R rotation of neckLateral bending neckPalpation: top, lat., ant.

17

p p, ,Shoulder abduction & add

D tData ga

Select new, f l duseful, discrim. info.

Data inter

f

Data inter

th iatheringInterpretexistingexistingdata

rpretationrpretationGruppen et al, 1991

Students select / uStudents select / unon-discriminating

(Mo

P emat e clos ePremature closure

use irrelevant oruse irrelevant or g info to bolster Dxotrin relieves pain…thus RA)

Friedman, 85% M3

Discriminatf lfor example,

dAge Nodes CImp m statusImp.m. status

No cough AsNo cough AsTachyp-cyan. ExTachyp cyan. ExSex - lung exp. F

ting featurest th t, strep. throat

CA/imm-supp.IV drug abuseIV drug abuse

sthma exacsthma exac.udate/red th.udate/red th.

Fever ...

20Wigton, 1986,’87,’89;Tape, 1991; Poses, 1992

Fdbk re: discFdbk re: disc

O t fdbk ( Outcome fdbk (

Cognitive (optimaS’ i ht )vs. S’s cue weights)

Cognitive + P b bilitProbability

rim. featuresrim. features

( / ) N(+/-) No

al + usein practicein practice

++C lib i

21Calibration

Integrating 5 bag g

1 Chief complaint (1. Chief complaint (2. Corresponding seo po d g3. PhEx maneuvers 4. Interpreting optim5. Documenting find

…learning in context -

asic elements…

(clinical context)(clinical context)

et of proto. Dxo p o o(Sole focus before!)

mal discrim. findingsdings & interpret.

22from rote to dynamic

Learning – aThe proThe pro

1. Study guide +1. Study guide +2. SP exam with 3. Debriefing: dis

assessmentcedurecedure

+ practice+ practiceimmediate fdbk

sclosure without blame

23

Study guide Study guide

Given CCs, prototypic Compare & contras Compare & contras

findings across p Learn maneuvers t

Build theiro n ep e ent tionown representation

– homework homework

cal Dx & maneuvers :st sort outst, sort out

pairs of Dxto make a Dx

n24

ns

ShouldShould

4 diagnoses: Bicipital tendonitis Adhesive capsulitis Adhesive capsulitis Rot. cuff tendonitis Referred pain

der painder pain1616 maneuvers:Point to areaFlexionInt. & external rotationNeck flexion & extensionL & R rotation of neck& otat o o ecLateral bending neckPalpation: top, lat., ant.

25

Palpation: top, lat., ant.Shoulder abduction & add

DiscriminatDiscriminat

Sh. pain B.tendo. Adh.S1S2S3S3S4S5…

S16

ting featuresting features

cap. Rot.Cuff T Ref.p.

26

DiscriminatiPositive negPositive – neg

Sh. pain B.tendo. Adh.S1 Sign +gS2 SigS3 Sign +S3 Sign +S4

SiS5 Sig… Sig

S16

ing features:gative findingsgative findings

cap. Rot.Cuff T Ref.p.Sign +g

n +Sign + Sign +Sign + Sign +

Sign +n +n +

27Sign +

Basic, pathophys.

Progressinflamminflammpart of j

Sub-acutendon overuse

Referred Referred

clinical mechanismssive, chronic

mation of the internalmation of the internal joint (intra artic.)

ute inflammation of a (extra artic.) due to ( )

ed pain dermatomesd pain, dermatomes

Study guide Study guide

System-base Video demos

P ti ith Practice with Practice on w Practice on w ……

+ practice + practice

d workshopss (Novi)

SP SPsward & in outptward & in outpt

29

Exam proExam pro

Gi b i f H &Given brief Hx & 1. Anticipate fi1. Anticipate fi2. Elicit physica3. Interpret fin4 SP feedback4. SP feedback

Revise, re-in5 D t f5. Document f

ocedureocedure

DDDDx:indings for each Dxindings for each Dxal findingsndings… working Dxk: redo if neededk: redo if neededterpret Dxi di & D

30indings & Dx

Ann 50 yrs old sees yAnn, 50 yrs old, sees yher right shoulder forespecially when she pespecially when she pare high as on a top

You’re thinking of posstendonitis or adhesivetendonitis or adhesiveanticipation of yourthe shoulder list thethe shoulder, list the associated with each hypothesishypothesis.

you because of pain inyou because of pain inr the past four weeks, picks things up thatpicks things up that shelf.

sible rotator cuff e capsulitis Ine capsulitis. In r physical exam ofpositive sign(s)positive sign(s) diagnostic

31

SPs & simulHearing loss Otitis medi

S31: Auditory acuity (S) Reduced audy y ( )acuity

S32: Inspect external ear No lesions presenMc

S33: Otoscope: internal ear (M) Otitis media side: Immobile butympanic membraopaque red coloropaque red color

S34: Rinne test(air conduction> bone)

(S) Bone conduclonger than air conduction on rig

Mcg

(NB)S35: Weber (apex skull)

( toward air (S) Sound better right side.

conduction; away bone cond.)

(NB) M

www.uptodate.c

lator modelsia Sudden viral hearing lo ss

ditory Reduced auditory acuityy y y

nt Possible vesicles in herpescGee 839

of right ulging ane, dull

Normal tympanic appearance without fluid

ction

ght side

Air conduction longer than bone conduction bilaterallycGee 839

g

r in the Sound better in the left side

cGee 839

com v15.2 Evaluation of hearing loss in adults

Data interpData interp

Given the results of ywhich diagnosis is mwhich diagnosis is m[ ] Rotator cuff te[ ] Adh i[ ] Adhesive caps[ ] Neither becaus[ ] Neither becaus

ambiguous or[ ] D ’t k[ ] Don’t know; w

pretationpretation

your physical exam, most likely?most likely?endonitis

litisulitis (frozen shoulder)se the findings arese the findings are r contradictory

ld b i33

would be guessing

SP feedSP feed

Immediate : -feedback o

--

d Redo

Do you wish to r

dback (see Wigtondback (see Wigton,Ericsson)

incorrect (SP demo)oromitted maneuversomitted maneuvers

34revise your Dx?

MaximizeMaximize

“D lib t i d“Deliberate mixed pra

Deliberate: plannep Mixed: Shoulder pa P ti l t Practice… lots…With feedback…d

e transfere transfer

ti ith f db k”actice with feedback”A. Ericsson, 2003H t l t l 1999Hatala et al, 1999

ed 19CC-160M-60Dxain: MS, Cardio, GI

cognitive, indiv & gr.

35

og , d & g“learning from errors”

Fdbk: StudenAnticipate Elicit

t Profiles (8)

Interpret

Group profile

Name

Antic. signs-Arter.

Antic.signs-

Elicit PhEx

Oblit. Stenosis man.

Student-2 86% 100% 71

St d t 3 57 100 71Student-3 57 100 71

Student-4 43 100 71

Student-5 57 100 86Student 5 57 100 86

Student-6 71 50 71

Student-9 57 100 86

Student-10 57 0.0 57

Student-12 29 50 29

Class aver 56% 75% 68%

& feedback

Interpret: Interpret: Docum. Working Dx Revised Dx findings

100 100 40

100 100 100100 100 100

100 100 80

100 100 50100 100 50

100 100 80

0 0 20

0 0 80

0 0 0.0

63% 63% 54%

Meeting witMeeting wit

Discuss their erronon–threateningnon threatening “Disclosure wi

Cognitive feedbac- discrim. featu

errors vs opti- errors vs. opti

th attendingth attending

ors in asettingsetting

ithout blame”

ck… to linkres & Dximal strategy

38

imal strategy

…in summary:y

See more findings Solid foundation Solid foundation Sort out DDx Dis

Contextualized… mContextualized… m Cognitive feedback,

disclosure witho

: 5 main goalsg

DDx in mind, earlyPrototypical DxsPrototypical Dxs

scriminating featuresg

maximize transfermaximize transfer, individual & group

39hout blame

Validity evidenValidity eviden

C t t lidit Content validity: Performance est Performance est H1: Discriminatingg

more reliable entire set of mentire set of m

H2: Long-term reH2: Long term reby receiving im

nce: 4 studiesnce: 4 studies

: Dxs, discr. features, refs.

tim : Students profilestim.: Students profiles

ng findings provideg g pe measures than maneuvers (checklist)maneuvers (checklist)

etention enhanced40

etention enhanced mmediate SP fdbk

Content vContent v

8 clinicians experiePhE f US CPhEx from US, Can

Reviewed & comme19 cases, protot.19 cases, protot.& add references

validityvalidity

nced in teaching d E & Jnada, Europe & Japan

ented onDx & corresp. signs Dx & corresp. signs

s (evidence-b.)

41

Content vaContent va

Suggestions led to 2 Suggestions led to 2- Maneuvers & sig

(2 %)- Dx (21%)- Added reference

Went from anatomto Dx reasto Dx reas

Ex.: Chest: lungs onto lungsto lungs

alidationalidation

226 modifications:226 modifications:gns (65%)

es to EBM basemical organization

soning organizationsoning organizationnly+ JVD + pedal edema

42

+ JVD + pedal edema

Indiv. studentIndiv. student

1.Anticip. signs: Dx-1Dx-2

2 Elicit PhEx man2.Elicit PhEx man.3.Interpret: Work. Dx4.Interpret: Rev. Dx5 Documentation5.Documentation

WebSP® - Lionis, Hungary

t fdbk- profilet fdbk profile

Case 1 Case 2Case-1 Case-229 (57) 75 (68)

50 (75) 75 (78)

29 (71) 60 (80)29 (71) 60 (80)

0 (53) 0 (73)

0 (60) 100 (87)

0 (54) 60 (66)43

0 (54) 60 (66)

Student-AStudent-ACCorr

Anticipation XAnticipation X

Maneuvers X

Interpretation: Xunprompted

Interpretation:e p e a oprompted

A profileA profilet I i l trect Inc, incomplete

XX

X

X

44

Student-BStudent-BCCorr

Anticipation XAnticipation X

Maneuvers

Interpretation:unprompted

Interpretation: Xe p e a oprompted

B profileB profilet I i l trect Inc, incomplete

XX

X

X

X

45

Student PrAnticipate Elicit

rofiles (8)

Interpret 6% 2 2 5 1 1 47 18 18 5 17

How mafor reliable a

Generalisability sy

Total listTotal list M3s

3 cases : 353 cases : .35 D-studyy

6 cases : .5612 cases : 6812 cases : .6822 cases : .80

ny casesassessment ?study: φ coefficienty φ

Discrim. signsDiscrim. signs

50.50

.7180.80

Impact of prior e ton reten

66 M3s IM clkship66 M3s IM clkship

St d t h t Student cohorts prep. 6 of 18

l i t i complaints using study guide

-

Assessed on3 of 6 complaints

--p

experiences (M3)ti (M4)ntion (M4)

125 M4 exam125 M4 exam

Assessed onAssessed on3 of 6 complaintsSome students:Some students:- not seen/ studied c.

di d d- studied, not tested - tested on same

48complaint /w SP fdbk

Impact of prior ton reten

Dxaccuracy

NS

experiences (M3)ti (M4)ntion (M4)

p<.05

49

Study gudid t hdid not hav

Dx problemsan SP withan SP with

enhalong-term

uide aloneff tve an effect

s tested withh feedbackh feedbackanced retention

Anticipate, elp ,findings in con

Key role of discriminfor analytical reason

Detailed profiles to fp Disclosure without Reliable & feasible (Reliable & feasible (

Better long-term retengimmediate feedback

icit & interpretpntext & thinking

nating findings (+/-)ningfocus fdbk & instructionblame(12 complaints)(12 complaints)

ntion with

51

k from SP

Future plans…p

Replace HTT with Hintegrated with clinteg ated t c

Add Hx component;Eva Eva,

Introduce HDPhEx in

Use discriminating itlibrary of key-feat

… developmentp

DPhEx in M2 year,nical pathologyca pat o ogy anal. & non-anal. 2006; Ark et al 2006 2006; Ark et al, 2006

n M3 yr, reinforcement

tems to build cklists:

52ture items linked to Dx

Future plansp

HDPhEx - As initial learn Phlearn Ph

- Reinforce

Validity data from ot

Differentiate SP from Differentiate SP from

s… research

method (M1-2) to ExExement in M3-4 yrs

ther sites

m SP+Fdbk effect53

m SP+Fdbk effect

QuesQuestionstions

Beyond checklist to Hypothesis drHypothesis-dr

Hx + Diff. Dx : in c

Anticipate : disc

Eli it i Elicit signs : cor

Interpret : anaInterpret : ana

Be corrected : imm

Document : rep

context & meaning riven Ph Examriven Ph Exam

context

criminating findings

trrect maneuvers

alytical thinkingalytical thinking

mediate feedback

56porting accuracy

bordagg

Bordage Med. Ed. 1987, 21:183-188g ,Bordage Ac. Med. 1994, 69: 883-85Chang et al. Ac. Med., 1998, 73: S10Connell et al. Ac. Med. 1999, 74: S1Bordage Ac. Med. 1999, 74: S138-43Nendaz & Bordage, Med. Ed. 2002:3Norman, NEJM, 2006;355:2251-52E M d Ed 2005Eva, Med. Ed., 2005Ark et al, Med Ed., 2007;41:281-87Van der V. & Schuwirth, Med Educ 2Ericsson et al. Psychol Rev. 1993; 10Hatala et al. J Gen Intern Med. 1999

ge@uic.edug @

85109-S11110-S124336: 760-66

2005, 39, 309-31700:363-406.9; 14:126-9.