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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 ?
http://photos2.meetupstatic.com/photos/event/7/9/c/4/event_99331172.jpeg
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?
http://photos2.meetupstatic.com/photos/event/7/9/c/4/event_99331172.jpeg
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 ?
http://photos2.meetupstatic.com/photos/event/7/9/c/4/event_99331172.jpeg
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