Teaching Clinical Reasoning “On the Fly” Part 1

1. Teaching Clinical Reasoning“On the Fly” Part 1 Donald R. Bordley, M.D. Residency Program Director University of Rochester (585) 275-2874 donald_bordley@urmc.rochester.edu

2. Key Points to Remember • Teach while you work • Clinical reasoning is most effectively taught as you care for patients together, not in a lecture hall or conference room • Live what you teach • If you don’t “role model” sound clinical reasoning as you discuss all your patients, the students won’t think it’s really important

3. Clinical Reasoning:Steps to Success • GATHER DATA CAREFULLY • Define the patient’s central problem • Generate and prioritize the differential diagnosis • Plan your work-up based on the differential diagnosis

4. Step 1 • GATHER DATA CAREFULLYAll subsequent steps in the clinical reasoning process depend on: • Accurate history • Accurate physical exam • Accurate lab data (if relevant) • Involve the student • Students have the luxury of time to do this well and this step can be partially delegated to them.

5. Step 2 • Define the patient’s central problem • List problems • Define central problem(s) • What’s in the foreground? • What’s in the background? • State the central problem clearly and concisely • (Foreground)in a (patient)with (background) • For example: Hemoptysis in a 62 y.o. woman with an 80 pack-year smoking history

6. Step 3 • Generate and prioritize the differential diagnosis • Start with a complete list: common things are common, but don’t miss high stakes diagnoses • For each possible diagnosis decide, is it: • Likely? • Possible and high stakes (potentially lethal or requires prompt specific therapy)? • Possible and low stakes? • Unlikely?

7. Step 4 • Plan work-up based on differential diagnosis • Aggressively work-up all “likely” diagnoses • Aggressively work-up all “possible high stakes” diagnoses • Defer work-up of possible low stakes and unlikely diagnoses

8. Practice Case Step 1:Data Collection • Mr. Jones is a 55 y.o. man who presented to the ED this afternoon after developing the sudden onset of chest pain after he had a coughing fit while mowing his lawn. The pain is constant and sharp, made worse with inspiration and associated with moderate dyspnea. Past history is positive for hypertension, type 2 diabetes, high cholesterol and seasonal allergies.Abnormal findings on physical exam: HR 120, BP 150/90, R 28, O2 sat 92% on room air. Absent breath sounds over the right chest. There is no JVD and the trachea is midline.

9. Practice Case Step 2:Define the Patient’s Central Problem • Problem list • Foreground: • chest pain, dyspnea, absent right breath sounds • Background: • HTN, Type 2 DM, high cholesterol • Central problem statement • Chest pain, dyspnea and absent right breath sounds in a 52 y.o. man with HTN, Type 2 DM, and high cholesterol

10. Practice Case Step 3:Prioritize the Differential Diagnosis • Likely • pneumothorax • Possible, high stakes • acute coronary syndrome • Possible, low stakes • muscle tear, rib fracture • Unlikely • aortic dissection, pericarditis, pneumonia

11. Practice Case Step 4:Plan Work-up Based on Differential • Work up the likely diagnosis • CXR • Work-up the possible, high stakes diagnoses • acute coronary syndrome - EKG • Defer work-up of other possibilities

12. CXR

13. Bottom Line • Teach as you work and live what you teach! • Be systematic and think out loud • What are the problems? Foreground and background. • What’s the differential? Focus on likelies and high stakes possibles. • Let your differential drive work-up and management