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

1. “We’re pretty sure it’s theWest Nile virus.”

2. Assessment of Diagnostic Reasoning and Clinical ThoughtChart Stimulated Recall

3. 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

4. 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” Critical Thinking Krupat 2011

5. 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

6. Key Elements of Diagnostic Reasoning Patient’s story Knowledge Data acquisition Accurate “problem representation” Context Generation of hypothesis Experience Search for and selection - illness script Diagnosis Bowen JL. NEJM; 2006: 2217

7. 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.

8. 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

9. Illness script Selected (Non-analytic) Pattern identified Clinical presentation No clear Pattern Hypothesis based Deductive reasoning (Analytic)

10. 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.

11. 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).

12. Pattern – illness script Elderly Subacute Recent medical intervention Oligoarticular Non-systemic Inflammatory Pseudogout

13. 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

14. 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

15. 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

16. Chart Stimulated Recall Requirements: • Conducted by medical faculty • Faculty development needed • Ideally, the medical record is reviewed in advance to identify specific questions

17. 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

18. 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?

19. 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?

20. Overall Note: Clarity____________________________________ Organization ____________________________________ Documentation____________________________________ Internal Consistency - Identify any disconnects in the history and physical.

21. Night Float CSR

22. How might your program utilize a CSR exercise?

23. 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!

24. 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

25. Questions