Teaching Students to Think Geriatrically

1. Teaching Students to Think Geriatrically D.W. Reynolds Foundation Annual Meeting October 24, 2011 Amit Shah, MD University of Texas Southwestern Dallas Cynthia Brown, MD, MSPH University of Alabama at Birmingham HoumanJavedan, MD Harvard University

2. What is a geriatrician? “….as a geriatrician, I am by definition an expert in subtlety and complexity” Hazzard, W. “I Am a Geriatrician” JAGS 52:161, 2004

3. Teaching with aphorisms and pearls….. • “Always remember the atypical presentation of disease. The older patient often won’t have read the textbook.” • “If you’ve seen one 80 year old, you’ve seen one 80 year old.” • “Occam’s Razor is dangerous” • “Multifactorial etiologies demand multifactorial solutions”

4. We can do better…Teaching trainees to think

5. Outline for today • Background about clinical reasoning • Teaching of clinical reasoning in novice trainees (medical students) • Teaching and assessment of clinical reasoning in advanced trainees (fellows) • Clinical Reasoning Case Practice (in a small group)

6. What is clinical reasoning? AKA: • problem-solving • decision-making • “judgment” • diagnostic reasoning • Major domain of clinical competence • Thinking and decision-making processes that are used in clinical practice

7. Two Major Types of Clinical Reasoning • Analytic (hypothetico-deductive) • What is generally emphasized in teaching • Bayes' theorem • EBM • Generation of rules • Non-analytic • Illness Scripts • Pattern recognition • “Experience” • Subconscious/automatic Figures from: Eva KW. What every teacher needs to know about clinical reasoning. Medical Education 2004; 39: 98–106

8. Which is better? • Non-analytic plays a much larger role in clinical care than we teach • Non-analytic has not been shown to be inferior • Excessive reliance on pattern recognition can cause diagnostic errors • Want to teach students to use both • Example: EKG reading teaching study Norman GR, Brooks LR, Colle CL, Hatala RM. The benefit of diagnostic hypotheses in clinical reasoning: experimental study of an instructional intervention for forward and backward reasoning. Cognit Instruct 2000;17:433–48

9. Non-analytic Teaching • Can teach illness scripts and pattern recognition • One Model: Many cases, rapid fire method • KBIT at TCOM (Dr. Frank Papa) • Pattern matching and pattern discrimination • Diagnostic competence is • problem specific • disease-specific • Explains why PBL/CBLs have limitations • Rapid Fire, multiple cases have a role (eg Prognosis app) Papa FJ, Oglesby MW, Aldrich DG, Schaller F, Cipher DJ. Improving diagnostic capabilities of medical students via application of cognitive sciences-derived learning principles. Medical Education, 41:419-425, 2007

10. Areas of Clinical ReasoningWong et al’s analytical model • Hypothesis Cues • Hypothesis Refinement • Testing Threshold • Treating Threshold

11. Geriatrically Thinking about Hypothesis Cues • Atypical Presentation of Disease • Importance of Corollary Informants • Picking up subtle clues from the environment • Home visits

12. Geriatrically Thinking about Hypothesis Refinement • Multifactorial etiologies • Syndromal Presentation • Incidence specific to age groups

13. Geriatrically Thinking about Testing Thresholds • Increased risk of harm from testing • Increased likelihood of false positive tests • Prognostication • Goals of care • Cost/benefit

14. Geriatrically Thinking about Treating Thresholds • Polypharmacy/non-pharmacologic management • Paucity of therapeutic evidence in advanced age groups • Individualized threshold/fluctuating threshold • Importance of interdisciplinary care • Impacts of goals of care

15. The Novice Learner

16. The Old Way of Becoming An Expert

17. Mismatch Between Teaching and Practice What is Taught What they observe • Step-by-step approaches • Book knowledge • EBM and Bayesian Analysis • Hypothesis testing • Thorough/ Luxury of Time • Quick, snap judgments • “Wisdom” “Experience” • “Fast and Frugal” or “Flesh and Blood” (real world) • Pattern recognition and seemingly automatic retrieval from the subconscious • Shortcuts

18. Clinical Guidelines and Cookbook Medicine • Great for simple, straightforward, typical patient • NOT SO GREAT FOR GERIATRICS! • Help reduce variability in clinical practice • But we teach the “heterogeneity of aging” : • Speed rate new knowledge applied • Can be good, but previous disasters with rapid adoption of untested practice/medications in the geriatric patient (eg, Vioxx, RALES trial, etc) Why trainees love them: • Clear answer of “what to do next” • Clear targets / goals of treatment • Simplify things / “take away the uncertainty”

19. Problems of Novice Trainees • Analytic strategies more rigid and simplistic • Over-reliance on algorithms • Inability to account for uncertainty What can we do? • Teach which hypothesis cues are important in a given context • Refining hypotheses when additional data available.

20. How will we teach them? • New National Curriculum: POGOe web-GEM • Disclaimer: Both myself and Amit Shah are involved in this initiative • Teach trainees explicitly about thinking and cognitive errors • Our niche as geriatricians, given our patients disproportionately suffer consequences of cognitive errors!

21. POGOe web-GEM Curriculum • Standardized Peer-Reviewed Curriculum • 34 cases in development • Authors from numerous institutions • Linked to AAMC Competencies • At the 3rd/4th year medical student level of detail • Have a “clerkship home” to allow integration for schools without mandatory geriatrics rotation • Emphasize core topics important to third year medical students in the case’s “clerkship home”

22. POGOe web-GEMs and Thinking Skills • Using the CASUS platform • Same platform used by medU (SIMPLE, CLIPP) • 1.5 million cases completed to date Clinical Reasoning Features: • Hypothesis Generation • Diagnostic Networks • Hypothesis Refinement

26. POGOe web-GEM Curriculum • Explicit focus on teaching novice trainees to “think like a geriatrician” • Syndromal Presentations • Atypical Presentations • Interprofessional approaches to evaluation and treatment

27. Teaching about Cognitive Errors • Well developed literature (from cognitive psychology) about diagnostic errors • Popularized by Dr. Jerome Groopman • Explicit teaching to novice trainees may: • help to develop good thinking habits • demystify process of coming to diagnosis Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775-780. Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med. 2003;41:110-120. Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142:115-120.

28. How do cognitive errors occur? • Typically not in isolation • Cascade of sequential cognitive mistakes • Much more common that novice trainees think • Up to 10% of autopsies reveal a clinically relevant diagnosis that was missed • Misdiagnosis occurs 15-20% of the time; about 80% are due to cognitive errors • Technology not a solution • Increased technology can increase misdiagnosis

29. Types of Cognitive Errors • Over 30-40 types of cognitive errors described in literature • Common types of error easily taught during care of geriatric patients: • Premature Closure • Framing or Diagnosis Momentum • Availability • Representativeness Errors • Attribution • Commission Bias and Omission Bias

30. Premature Closure or “Freezing” • Once have something that “fits” you stop thinking • Also has been called “satisficing error” • Satisfy + suffice • Examples in Geriatrics: • Hospital patient with pneumonia who has a MI • “The fracture most commonly missed is the second” • Delirious patient with multifactorial etiology (stopping work-up with positive U/A and miss MI or meningitis)

31. Framing or Diagnosis Momentum Once several doctors/specialists agree on a diagnosis it is easier to perpetuate it rather than take the time to question its accuracy • In Geriatrics: • “Chart Lore” for PMH • “ED admits this delirious patient with a UTI from the NH”

32. Availability Errors • Choosing most likely or most memorable diagnosis • Over-estimation of frequency of vivid or easily recalled events • Under-estimation of frequency of ordinary or hard to recall events

33. Representativeness • Removing a disease from differential diagnosis list because it does not match standard or usual presentation • A major problem in diagnosis of patients in whom “atypical presentations” are common, like geriatrics

34. Commission Bias(inability to follow geriatric mantra: “Don’t just do something, stand there”) • Urge to act rather than do nothing even when nothing is preferable. • Rooted in belief that beneficence involves active intervention Omission Bias (“They are just old”) • The tendency towards inaction • Events attributed to natural events of disease better than those related to a physician’s intervention • Rooted in non-malfescence

35. Attribution Errors • Stereotyping • Judgmental • Gender Bias • Racial Bias • Age Bias

36. Teaching avoidance of cognitive errors • Make thinking explicit – Think out loud! • Feedback • Reflective Practice • Become comfortable with uncertainty • Acknowledgement we get it wrong at least 10% and up to 20% of time • Metacognition: “Cognitive Pills for Cognitive Ills”

37. The Advanced Learner

38. What is different about the advanced learner? • 1- Larger non-analytic reasoning data base • 2- Already adopted a form of analytical model • 3- Due to variability of experience and graduate medical education, variability of baseline knowledge and skills • 1+2+3 = Adult Learner1 1. Kolb, David (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall.

39. What is different about the new Geriatric learner? • Less likely to be exposed to geriatric clinical reasoning domains described at beginning of presentation • Well trained in clinical guidelines not based on the elderly (worked hard and invested heavily in achieving recognition for it) • Less likely to have experience in a nursing home or rehab setting

40. Where to Begin? • Clinical Reasoning studies • Think out loud2,3 • Ability to communicate reasons 2 Kassirer, J.P., Wong, J.B, Kopelman R.I. (2009). Learning Clinical Reasoning. New York: Lippincott Williams & Wilkins 3 Alberdi E, Taylor P, Lee R. Elicitation and representation of expert knowledge for computer aided diagnosis in mammography. Methods Inf Med. 2004;43(3):239-46.

41. Can You Teach Advanced Learners? • Adult Learning Curricula2 • Experiential learning (why, how, what, if)3 • Case based learning • Real life application (a.k.a. relevant) • Learning Objectives • Reflection4 2 Armstrong, Liz and Kegan, Robert. Harvard Macy Institute Curriculum for Educators. 3 Armstrong E, Parsa-Parsi R. How can physicians' learning styles drive educational planning? Acad Med. 2005 Jul;80(7):680-4 . 4 Stark P, Roberts C, Newble D, Bax N. Discovering professionalism through guided reflection. Med Teach. 2006 Feb;28(1):e25-31

42. What cognitive aspect makes it specifically geriatric? • If you had to develop a Geriatric Clinical Reasoning “Mini-Cog” to screen for geriatric clinical executive function what would be the clock draw? • UNCERTAINTY

43. Clinical Reasoning Curriculum • Task: • A validated adult learning method that incorporates recognized clinical reasoning methods targeting geriatric reasoning by using uncertainty as a core theme.

44. Clinical Reasoning Curriculum • Design: • A case based learning format • Part of weekly didactics • Introductory lecture describing basics of analytical and non-analytical clinical reasoning • Reflective session half way through • Provide copy of learning objectives with relevant list of geriatric knowledge and skills topics • Provide template of Wong model presentation PowerPoint for case presentation

45. Clinical Reasoning Curriculum • Design: • Designated fellow will present a real clinical case encountered during rotation or NH overnight call • After presenting the case the presenting fellow will choose question from one of the Wong model domains • The group will then divide into groups of 2 to 3 fellows and discuss the question for 5-10 minutes

46. Clinical Reasoning Curriculum • Design: • A representative from each group will present the reasoning behind their clinical decision to the whole group • The presenting fellow will summarize each groups key reasons to confirm they are understood correctly • The presenting fellow will share the outcomes of the case if known • The presenting fellow will present the results of a literature search if any relevant evidence exists

47. Learning Objectives

48. Template • Hypothesis Cues • What signs and symptoms are significant and why? • Hypothesis Refinement • What are your likely diagnoses and why? • Testing Threshold • What tests would you request and why? • Treatment Threshold • What treatment would you implement and why?

49. Clinical Reasoning Curriculum • How is this different from morning report?: • 1- Case must not have a single correct answer (must include uncertainty) • 2- The level of uncertainty should increase over the course of the year • 3- The focus is on why a decision should be made not the list of options?

50. Practice Case