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Beyond Read More!

Franklin Square Hospital Center Baltimore, MD. Beyond Read More!. Incorporating Adult Learning Theory into Postgraduate Medical Education. Frederick Williams, MD. Learner Maturation. Minimum Acceptable Level. Competency. A. B. C. PGY1. PGY2. PGY3. Learning Objectives.

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Beyond Read More!

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  1. Franklin Square Hospital Center Baltimore, MD Beyond Read More! Incorporating Adult Learning Theory into Postgraduate Medical Education Frederick Williams, MD

  2. Learner Maturation Minimum Acceptable Level Competency A B C PGY1 PGY2 PGY3

  3. Learning Objectives • Understand current concepts problem solving strategies derived from adult learning theory. • Appreciate the importance of knowledge organization/acquisition in problem-solving • Review how we as educators can facilitate more efficient and accurate problem-solving by the way we teach

  4. Learner Maturation Data Gathering Accuracy Expert Novice

  5. History Physical Exam Laboratory Data X-rays Diagnosis

  6. Building Blocks of Problem Solving Inductive Reasoning Deductive Reasoning Pattern Recognition

  7. Inductive Reasoning Case: 35 year old AA female with one day hx of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93%

  8. Diff Dx: CAD Pneumonia Pericarditis PE Musculoskeletal Pleuritis GERD Inductive Reasoning Case: 35 year old AA female with one day hx of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93%

  9. Inductive Reasoning Case: 35 year old AA female with one day hx of sharp, left-sidedchest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93% • Diff Dx: • CAD • Pneumonia • Pericarditis • PE • Musculoskeletal • Pleuritis • GERD

  10. Inductive Reasoning Case: 35 year old AA female with one day hx of sharp, left-sidedchest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93% • Diff Dx: • CAD • Pneumonia • Pericarditis • PE • Musculoskeletal • Pleuritis • GERD

  11. Inductive Reasoning Case: 35 year old AA female with one day hx of sharp, left-sidedchest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93% • Diff Dx: • CAD • Pneumonia • Pericarditis • PE • Musculoskeletal • Pleuritis • GERD

  12. Inductive Reasoning • Single symptom driven data collection • Redundancy of information • Large amount of data • Success dependent on initial differential dx

  13. Acute Pleuritic Chest Pain Deductive Reasoning: Defining the Syndrome Case: 35 year old AA female with one day hx of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93%

  14. Chest pain

  15. Acute Chronic Chest pain

  16. Pleuritic Acute Chronic Acute Nonpleuritic Chest pain

  17. Deductive Reasoning • Unit of Diagnosis is the SYNDROME • Initial Data gathering is to define the syndrome • More Efficient/Less data • each step excludes multiple dx possibilities • Key Skills Needed: Processing/Transformation of Symptoms Compare and Contrast Mentality

  18. Processing Unprocessed Processed One day history Acute Sharp, worse with Pleuritic inspiration and coughing Occurring at rest Nonexertional

  19. Temporal Processing Symptom Pattern Qualitative Descriptor Epidemiology Common Syndrome Thematic Summary Acute vs Chronic Progressive Colicky pain Immunocompetent Delirium, Shock, CHF Destructive thrombocytopenia without coagulopathy Examples of Processing Descriptive Summative

  20. Recognition Pattern

  21. Illness Scripts *Inc A-a Grad *Acute onset SOB *Pleuritic chest pain *Calf tenderness *hemoptysis *Travel Pulmonary Embolism

  22. Travel? A-a Grad Calf Pain?

  23. Pattern Recognition Case: 35 year old AA female with one day hx of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93%

  24. Pattern Recognition Case: 35 year old AA female with one day hx of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, some SOB. Meds: OCPs , Recent trip to London. Normal exam except tachycardic. Pulse ox 93% Pulmonary Embolism

  25. Pattern Recognition • Unit of Diagnosis is the Disease • Skills Required: Grouping of Processed Symptoms Compare and Contrast Mentality Understanding of Key Features Data Acquisition for missing features Experience

  26. Sort information Search for Patterns Select key findings Pauci-clue, Long Differential Diagnosis Inductive Deductive Targeted Differential Diagnosis Clinical Information Single Diagnosis Immediate recognition of distinct pattern Pattern Recognition

  27. Learner Maturation Data Gathering Accuracy Expert Novice

  28. Learner Maturation 100% % Deductive Reasoning and Pattern Recognition % Inductive Reasoning 0% Novice Expert

  29. Knowledge Organization • The development of sophisticated problem solving skills involves not only an increase in the number of facts but a change in the way those facts are stored and used. Georges Bordage, MD Ph.D.

  30. Knowledge Organization Exercise I

  31. 1 2 3 4 5 6 7 8 12 9 10 11 13 14 15 16 17 18 19 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

  32. 1 2 3 4 5 6 7 8 12 9 10 11 13 14 15 16 17 18 19 20 1 2 3 4 5 7 8 9 10 11 13 15 16 17 18 19 20

  33. 1 2 3 4 5 6 7 8 12 9 10 11 13 14 15 16 17 18 19 20

  34. Knowledge Organization • Reduced Knowledge • Dispersed Knowledge • Elaborated Knowledge • Compiled Knowledge Bordage, et.al

  35. Reduced: few facts, poorly organized Dispersed: many facts, poorly organized Elaborated: many facts, logically organized to facilitate forward thinking Compiled: robust repertoire of illness scripts Qualitative and Quantitative Differences

  36. Group Exercise II • Review the Responses each learner makes to the morning report case presentation • Compare and contrast the different case analysis styles according to the questions posed • Identify what type of knowledge organization schema they are using

  37. Dr. Red: Reduced ?? B12 Deficiency

  38. Reduced Knowledge Structure • True Paucity of Accessible Knowledge • Unit of Dx: Single Clue • Can’t use additional facts: don’t help • If no trigger with single clue: give up • Logic: Random Guess (sometimes right!) • Illness scripts: sketchy, disorganized, anemic

  39. Dr. Yellow: Dispersed SCC Guillain Barre ? ? Stroke ? ALS Hypo- K

  40. Dispersed Characteristics • “Forest for the Trees” • Thorough problem list but no Processing • no syndrome identification • Unit of Diagnosis: Single Clue, Random Selection • Illness scripts: more facts than reduced but still no relational component

  41. Elaborated/Compiled Learners: LMN HIV Myopathy Leg weakness ID MS TM SCC UMN HAM Myelo- pathy Rheum Brain

  42. What Happens at a Node? X = The syndrome of lower extremity weakness Rhabdo Myopathy UMN reflex no sensory abn tone global distrib X myalgia toes stroke vs SCC M, S reflexes LMN distrib :asc,pn, rad GBS, Amyotrophy neuralgia

  43. Elaborated/Compiled Features • Unit of Diagnosis: Symptoms Processed to Syndromes • Systematic Approach: • logical progress through a series of interconnected nodes which emphasize disease/syndrome relationships • Illness Scripts: Robust, Syndrome Centered • Understands Key Features

  44. Not Helpful Dr. Red: Reduced Dr. Yellow: Dispersed Helpful Dr. Blue: Elaborated Dr. Green: Compiled Knowledge Organization Styles these are different organizational schemes: the learner does not need to progress through the reduced and dispersed phase to get to the elaborated or compiled phase

  45. Can We Change The Way People Think and Learn? Reduced/Dispersed Elaborated/Compiled

  46. Teach Residents to: • Process information • Rely on multiple symptoms • Identification of Syndromes • Compare and Contrast Diagnostic Triads • Teaches Key Features • Building block of memory network • Build Accurate and Robust Illness Scripts

  47. Compare And Contrast Learning A method to encourage the development of forward thinking and pattern recognition

  48. Goals of Compare and Contrast Learning • Encourage the recognition of and use of syndromes as the unit of diagnosis • Reinforce that within a given syndrome, all facts are not created equal • Teach residents to build illness scripts based on key and differentiating features and to seek out these features when reading

  49. I. Read Vertically • Identify A Syndrome-Not a disease • Identify a Diagnostic Triad • Like diseases that can cause a specific syndrome • Complete Table • Syndrome Features: seen in all three • Distinguishing Features: seen in only 2/3 • Key Features: unique in this triad to a single dz

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