Incorporating Mechanism Maps in Teaching A Strategy for Enhancing Critical Thinking

1. A teaching hospital of Harvard Medical School Incorporating Mechanism Maps in TeachingA Strategy for Enhancing Critical Thinking Jeremy B. Richards, MD, MA Richard M. Schwartzstein, MD Shapiro Institute for Education and Research Beth Israel Deaconess Medical Center Harvard Medical School Education is at the heart of patient care.

2. Disclosures – Dr. Schwartzstein • Perspectives advisory board, New England Journal of Medicine • Editorial board, Chest • NIH funding for dyspnea research Disclosures – Dr. Richards • CRICO funding for quality improvement research

3. Today’s Goals Review cognitive science underlying the development of durable learning Delineate the dual system model of how we think when approaching new problems Describe the role of inductive reasoning in critical thinking Demonstrate the difference between classical concept maps and mechanisms maps Have you develop a mechanism map

4. What is critical thinking?

5. What does “work the problem” look like?

6. How we think…Dual Processing Conscious thought Unconscious thought Cognitive Biases

7. Judgment Under UncertaintyTversky and Kahneman, Science, 1974 “…people rely on a limited number of heuristic principles which reduce the number of complex tasks of assessing probabilities…to simpler judgmental operations” which can “lead to severe and systemic errors.”

8. Dual ProcessingCourtesy of P. Croskerry, MD, Millennium Conf 2011 Type 1 Processes RECOGNIZED Pattern Recognition Patient Presentation Pattern Processor Executive override Dysrationalia override Calibration DX Repetition Type 2 Processes NOT RECOGNIZED

9. Retention and Use of Knowledge Long term memory develops in three phases Information presentation** Information processing Information integration** How do you teach?** Do you look for frameworks for the knowledge to be learned? Do you build on prior learning?

10. How do students/residents learn?Modified fromHarasym et al. 2008 Surface Learning -- New info not linked to previous knowledge -- Knowledge abundant but disorganized -- Focus on memorization and recall -- Learns concepts and facts without reflection Deep Learning -- Relates new knowledge to previous knowledge -- Content organized into coherent whole -- Focus on problem-solving; apply, analyze -- Link concepts/principles to everyday experience

11. Deep vs. Superficial Learning Link new information to prior learning Create frameworks to help students organize and use knowledge “Understanding” beyond “knowing”

12. Routine vs. Adaptive ExpertMylopoulos M, Regehr G. Med Ed 2007 Routine Expert Novel problem  adapt problem to the solution with which they are comfortable Characterized by speed, accuracy, automaticity Adaptive Expert Use a new problem as a point of departure for exploration; expand knowledge and understanding Characterized by innovation, creativity

13. Expertise and Creativity

14. How do you solve problems? You put the key in the ignition, turn the key and the car doesn’t start. What’s the answer? How do you think about this problem?

15. Thinking ApproachesModified from Pottier et al. Med Ed 2010 Inductive Reasoning Deductive Reasoning

16. Structure and Use of Traditional Concept Map

17. “Mechanism” Maps Graphic devices to represent relationships between multiple concepts Reinforce mechanistic thinking Make links explicit

18. Concept vs. Mechanism Map

19. Increased ADH Decreased Na Acidemia Decreased preload Hypovolemia Decreased insulin Increased glucose Acute kidney injury Increased lactate Increased abdominal pressures Third-spacing Decreased CO Increased anaerobic metabolism Decreased chest-wall compliance Increased vascular permeability Decreased DO2 Hypotension Increased Palv Inflammatory response / cytokine Release Increased sympathetic activation Increased dead space Pancreatitis Increased PaCO2 Decreased calcium Increased HR

20. Increased ADH Decreased Na Acidemia Decreased preload Hypovolemia Decreased insulin Increased glucose Acute kidney injury Increased lactate Increased abdominal pressures Third-spacing Decreased CO Increased anaerobic metabolism Decreased chest-wall compliance Increased vascular permeability Decreased DO2 Hypotension Increased Palv Inflammatory response / cytokine Release Increased sympathetic activation Increased dead space Pancreatitis Increased PaCO2 Decreased calcium Increased HR

21. Student Comments Support Mechanism Maps Major themes: 1) Determine causality “Concept maps helped me look a causality and connections between different parts of the clinical presentation.” 2) Helped identify weaknesses “Concept maps forced me to challenge my understanding and helped me identify areas that needed more work.” 3) Integrated knowledge “Concept maps helped tie together constellation of symptoms and see how one physiological change can affect multiple organs or cause multiple symptoms.” 4) Helped develop hypotheses “Concept maps made me think of a broad array of causes for a specific symptom.”

22. Mechanism Maps Enhance Exam Performance Final Exam: Final exam was composed of 12 questions Case-based exam; mostly paragraph answers Focus of the exam – apply knowledge to solve problems Maximum possible score = 182 Overall – 156.0 (std. dev. 12.9) – Range 119-180.5 Group A – 157.5 (std. dev. 11.7) Groups B and C – 152.3 (std. dev. 13.1) F-statistic=3.34, p=0.07 priori level of significance of α=0.1. Veronese et al. Med Teach, In press.

23. Students’ mechanism maps

24. Students’ mechanism maps

25. Summary • Teaching/learning that emphasizes conceptual framework supports understanding and application of content • Inductive reasoning may facilitate adaptive expertise • Mechanism maps provide a strategy to reinforce basic concepts and teach students how to “work the problem”

26. Mechanism map examples • Topic- versus case-based concept maps

27. Case-based mechanism map 76yo woman with ~10 years of steadily worsening dyspnea, who now cannot walk more than half a block on flat ground due to breathlessness. She has smoked 10-20 cigarettes a day for 55 years. Recently, she has developed a productive cough and wheezing. Her exam is notable for a temperature of 98.7, BP 122/84, HR 98, RR 18, O2 sat 90% on room air. Her chest has low-lying diaphragms and is hyperresonant to percussion. She has decreased breath sounds and expiratory wheezes with an increased anteroposterior diameter. Heart sounds are distant. Fingernails are not clubbed or cyanotic. She has a 2+ lower extremity edema.

28. Case-based mechanism map • Identify and highlight core signs and symptoms • Identify pathophysiologic and clinical mechanisms that link these core signs and symptoms • Begin to link the core signs and symptoms using pathophysiologic mechanisms • Use linking words when needed • Be open to opportunities to cross-link concepts or expand the map in new directions

29. Case-based mechanism map 76yo woman with ~10 years of steadily worsening dyspnea, who now cannot walk more than half a block on flat ground due to breathlessness. She has smoked 10-20 cigarettesa day for 55 years. Recently, she has developed a productive cough and wheezing. Her exam is notable for a temperature of 98.7, BP 122/84, HR 98, RR 18, O2 sat 90% on room air. Her chest has low-lying diaphragms and is hyper-resonant to percussion. She has decreased breath sounds and expiratory wheezes with an increased anteroposterior diameter. Heart sounds are distant. Fingernails are not clubbed or cyanotic. She has a 2+ lower extremity edema.

30. Case-based mechanism map worsening dyspnea smokedcigarettes productive cough wheezing

31. Break-out groups • Time to put theory into practice! • Divide into groups of 4-5 • Each group will spend the next 20 minutes designing a mechanism map based on a case vignette • Highlight pathophysiologic mechanisms as they relate to clinical signs and symptoms • During the process, keep track of pros and cons of developing a mechanism map

32. Break-out groups? • Students were assigned to groups of 3 and instructed to produce a consensus concept map in response to questions about microbiology • Learning and performance was higher in students in groups with disparate backgrounds and different knowledge bases • Peer (and instructor) feedback reinforces learning beyond the act of building a concept map Kinchin I, Hay D. J AdvNurs2005;51(2):183–7 Morse D, Jutras F. CBE Life SciEduc 2008;7(2):243-53

33. Break-out groups • Time to put theory into practice! • Divide into groups of 4-5 • Each group will spend the next 20 minutes designing a mechanism map based on a case vignette • Highlight pathophysiologic mechanisms as they relate to clinical signs and symptoms • During the process, keep track of pros and cons of developing a mechanism map

34. Case vignette Mr. Green, a 47yo attorney and former heavy drinker, presents with a 6 month history of marked fatigue and dyspnea on minimal exertion. He tells you, “I feel so tired by lunch time that I have to go home to sleep.” He has also had decreased exertion, and has cut his daily 2 mile walk to 1 mile, a half mile, and then stopped walking altogether. He cannot lie flat at night because he awakens 1-2 hours after going to sleep with dramatic shortness of breath. Over the last two weeks he has only been comfortable sleeping upright in a chair.

35. Case vignette Mr. Green, a 47yo attorney and former heavy drinker, presents with a 6 month history of marked fatigueand dyspneaon minimal exertion. He tells you, “I feel so tiredby lunch time that I have to go home to sleep.” He has also had decreased exertion, and has cut his daily 2 mile walk to 1 mile, a half mile, and then stopped walking altogether. He cannot lie flat at night because he awakens 1-2 hours after going to sleep with dramatic shortness of breath. Over the last two weeks he has only been comfortable sleeping upright in a chair.

36. Physiologic mechanisms Consider using these concepts / mechanisms in your map: • Preload • Afterload • Sympathetic nervous system • Contractility • Stroke volume • Heart rate • Diastolic (volume, pressure) • Systolic (volume, pressure) • Systemic vascular resistance • Oxygen delivery • Gas exchange • Hypertrophy