30/04/2019

1

Teaching clinical reasoning and novice to expert

AusDEM Workshop 2019

A/Prof Julia Harrison

• How did you learn to reason clinically?

• How is clinical reasoning generally taught in your craft group?

• Are you involved in teaching it?

• If so, how do you teach it?

Activity

2

30/04/2019

2

What is clinical reasoning?

• Assessing a patient and making decisions about management

1. Diagnostic reasoning

2. Management decision making

What clinical reasoning strategies are you aware of?

4

30/04/2019

3

Some clinical reasoning strategies

• Rules of thumb / heuristics• Pattern recognition / Gestalt• Hx, Ex, Dx, Ddx, Mx,• Hypothetico-deductive method• Exhaustive method• Protocols, pathways, guidelines, decision rules• 2nd opinion / discussion• Clinical reasoning sandwich

5

Forms of reasoning

• Non–analytic System 1

• Unconscious and automatic

• Fast

• Effortless

• Pattern recognition

• Intuition

• Requires experience

• Difficult to put into words

• not distractable

• Analytic System 2

• Conscious and controlled

• Slow

• Effortful

• Exhaustive method

• Hypothetico-deductive method

• Requires knowledge

• Easy to put into words

• distractable

6

30/04/2019

4

What is 15 X 26?

7

8

30/04/2019

5

9

10

30/04/2019

6

11

12

30/04/2019

7

13

Non-analytic reasoning• The Human brain is strongly wired to look for patterns

• It occurs unconsciously all the time

• Reinforced with exposure/experience

• Feedback improves accuracy and hastens progress

• Important part of clinical reasoning

• How can educators facilitate this form of reasoning?

14

30/04/2019

8

Analytic thinking

Exhaustive method

• Detective

Hypothetico-deductive

• Mechanic

What happens over time

Experienced Doctor

Exhaustive method

Pattern recognition

Hypothetico-deductive method

3rd year medical student

30/04/2019

9

Problem based Hx, Ex, Dx, Mxin the setting of work

Problem based Hx, Ex, Dx, Mx

Systems based Hx , Ex, Dx

Conditions and how they manifest (illness scripts)

Basic sciences, anat, phys, pharm ,path,

systems

Representations of clinical reasoning

• Dual Process Theory(Patrick Croskerry)

• Dynamic Decision Making

(Mica Endsley)

18

30/04/2019

10

19

The dual process theoryContext

Ambient conditions

Modular responsivity

Task difficulty

Task ambiguity

Affective state

Education

Training

Critical thinking

Logical competence

Rationality

Feedback

Intellectual ability

Pattern

Recognition

Repetition

Rational

override

Dysrationalia

overrideCalibration Response

Patient

Safety

Problem

Pattern

Processor

RECOGNIZED

NOT

RECOGNISED

System

1

System

2

Pat Croskerry

Gather

information

Make sense

of the

information

Predict

what could

happen

Make a

decision

Decision making in the real world

(Dynamic decision making):

Mica Endsley (2004)

Simplified version of her model of

situation awareness20

30/04/2019

11

Gather

information

Make sense

of the

information

Predict what

could

happen

Decide

what to do

All steps require a solid knowledge-base in the medical

sciences: anatomy, physiology, pathology, pharmacology.

Effective clinical reasoning is dependant on clinical and

cognitive skills in all four stages

Prerequisites for the development of these skills are

KNOWLEDGE and EXPERIENCE

There are pitfalls at each stage

21

Basic sciences

Conditions

Patient presentations

: Hx, Ex, Ix

30/04/2019

12

30/04/2019

13

Novice to Expert

Are some people better at clinical reasoning than others?

How can you tell?

25

30/04/2019

14

2 stories

• 3rd year medical student assessing a patient in the ED

• Fireman saving the lives of his crew(Gary Klein. Sources of Power – How people make decisions. 1998)

27

3 short cases

28

30/04/2019

15

1. An intern forgets her medical training

• 58 yr old lady with left leg and hip pain

• Plan following assessment:• US to exclude DVT

• Xray looking for OA of hip because there is pain on mvt of the joint and no Hxof trauma or strain.

30/04/2019

16

Experienced doctor sees a cellulitic looking leg and knows to palpate the inguinal nodes and check the temperature -nodes are very tender and enlarged and patient has a fever.

Dx of cellulitis confirmed, DVT and arthritis are no longer likely.

31

Learning from the case

• A good examination matters

• Don’t forget the basics eg “look, feel, move”

• Junior clinicians need to be more thorough in their assessments or they will miss things. This is because their pattern recognition is in the early stages of development.

• Experienced clinicians are better at recognising likely possibilities and honing in on relevant information.

30/04/2019

17

2. An ED reg misses an easy diagnosis

ED registrar sees middle aged man with a painful red swollen elbow. Concerned re septic arthritis.

No fever. Rings orthopaedic registrar - advised to take bloods and aspirate the joint.

ED registrar not sure where to put the needle.

Asks ED consultant to help.

34

30/04/2019

18

Consultant notes localised redness and tenderness around lateral epicondyle, patient still able to flex and extend elbow.

Consultant considers tennis elbow and asks about repetitive arm movementsPatient spent 6 hours delivering telephone books the day before.

R.I.C.E. patient reassured and septic arthritis no longer a consideration

35

What’s going on?

• Junior reg has never seen tennis elbow or septic arthritis of the elbow (book knowledge only), senior doctor has seen both

• Lots of teaching on the importance of not missing a septic joint, not much on tennis elbow

36

30/04/2019

19

Learning from the case

• Experience counts for a lot

• While you are waiting for more experience thoroughness is your friend

3. Beginner’s blindness

30/04/2019

20

• Junior reg sees a 21 year old man with a swollen painful hand after punching someone

• She diagnoses a punch fracture using pattern recognition, but can’t see the fracture on XRAY?

39

• Consultant “sees” a different pattern…

• Painful swollen hand following punching

• Patient presenting 3 days post punch

40

30/04/2019

21

41

• Relying on pattern recognition can be error prone -especially for inexperienced staff.

• Pattern recognition becomes more sophisticated with experience

• Juniors need to be thorough, try and make sense of everything. Read and ask questions as you go, shortcuts/patterns will develop over time.

42

30/04/2019

22

The Dreyfus model of skill acquisition

1. Novice

2. Advanced beginner

3. Competent

4. Proficient

5. Expert

6. (Master) Dreyfus and Dreyfus (1982)

Benner (1982)

Dreyfus, S (2004) The Five Stage Model of

Adult Skill Acquisition. Bulletin of Science,

Technology & Society 24(3) 177-181 43

1. Novice

• Use rules

• Rules are free of context• E.g. driving (distance behind car in front)

• E.g oxygen saturation

• Lack judgement

• Cannot trouble shoot

• Need to concentrate

• Initial rules allow for accumulation of experience.

• Rules will eventually need to be put aside/adjusted to proceed

44

30/04/2019

23

Teaching tip

• Beginners need rules

• Explain the reason behind the rule

• Make sure exceptions to rules are defined as such

45

5. Expertise

• When things are proceeding normally, experts don’t solve problems and don’t make decisions, they do what normally works

• Intuition

• Cannot readily articulate why they do what they do

• Totally involved

• High level of situation awareness

• E.g. – conversation, walking, raising children, reading

50

30/04/2019

24

“Expert nurses will sometimes sense that a

patient lies in danger of an imminent relapse

and urge remedial action upon a doctor. They

cannot always provide convincing, rational

explanations of their intuition, but very

frequently they turn out to be correct”

Dreyfus (1982)

51

“Intuitive grasp should not be confused with

mysticism since it is available only in situations

where a deep background understanding of the

situation exists.”

Benner (1984)

“Intuition is nothing more and nothing less than

recognition.”H. Simon (Nobel Laureate)

52

30/04/2019

25

6. Master

• Excels with challenge and surprise

• e.g. Magnus Carlson

• e.g. Miles Davis

54

30/04/2019

26

Master: Magnus Carlson

• “Carlson famously trusts his intuition. He may take 30 minutes to make a move but,…” I usually know what I am going to do after about 10 seconds; the rest is double checking. Often I cannot explain a certain move, only I know that it feels right, and it seems that my intuition is right more often than not”.

• All The Right Moves, The Age Good Weekend Magazine March 5 2014

55

Master: Miles Davis

56

30/04/2019

27

Differences between novices and experts

• Pattern recognition

• Chunking

• Automaticity

• Neuroanatomical changes

• Physiologic changes (for physical skills)

57

58

30/04/2019

28

Recall after 5 sec. exposure

<1650 1650-2000 2000-2350 >2350

59

10,000 hours

• Based on work by Anders Ericsson

• Violinists, chess players, at the “elite” level.

• Needs to be 10,000 hours of deliberate practice

“ten years of living in a cave does not make a geologist” (Ericsson)

60

30/04/2019

29

*

*

61

Deliberate Practice

• Is challenging

• Requires self discipline

• Requires concentration

• Requires Determination / Motivation

• Is dependant on feedback

• Greatly aided by a coach / teacher

62

30/04/2019

30

Vygotsky’s zone of proximal development

Can do

independently

Cannot do even with help

ZPD

Can do with help

63

Vygotsky’s zone of proximal development

Can do

independently

Cannot do even with help

ZPD

Can do with help

Too hard / anxiety zone

Too easy/Comfort zone

Just right / learning zone

64

30/04/2019

31

Novice to expert

• Can’t skip stages• A novice can imitate an expert but will make mistakes

• Not everyone progresses to be an expert

• People progress at different rates

65

Challenges for teaching and learning clinical reasoning• Reasoning cannot be observed

• Experts cannot readily explain how they do it

• Discipline specific

• Content knowledge is required

• Experts do it differently to novices

66

30/04/2019

32

The ha ha wall analogy

67

30/04/2019

33

How do learners progress?

• Experience is essential – need to see lots of cases

(but experience alone doesn’t guarantee expertise)

• Learners must:• Reflect on experience

• Learn from the experience

• Get feedback

69

How can you find the right pitch in your teaching?

30/04/2019

34

Adaptive expertise

Implications for clinical teachers

• Think about your own clinical reasoning

• Learners must have real world experiences

• Facilitate learning from experience• Help sharpen perceptual skills

• Reflection, thinking, planning

• Provide feedback for students

• Help learners develop rules and recognise patterns, encourage them to make links to similar situations, compare and contrast

72

30/04/2019

35

Implications for clinical teachers cont…

• Students need broad experience

• break things down – e.g. sick child

• Content must be learner-centred - an expert can’t predict where the novice is at

• Encourage reflection on experience

• Make your own reasoning explicit

73

Take home points

• Clinical reasoning is complex - humans don’t think like machines

• Both analytic and non-analytic processes are used

• Experience is vital for learning, but experience alone doesn’t create expertise• We need to encourage reflective practice

• You can’t teach novice students to think like you (assuming you are expert), but you can facilitate the learning process

• Expertise doesn’t guarantee infallibility

74

30/04/2019

36

Further Reading

• Patricia Benner

• Dreyfus & Dreyfus

• Pat Croskerry

• Geoff Norman

• Jerome Groopman

• Anders Ericsson

75

‘The art of medicine is to be learned only

by experience: it cannot be revealed.

Learn to see, learn to hear, learn to feel,

learn to smell, and know that by practice

alone can you become expert’

Osler, 1919

76