Teaching Clinical Reasoning On the Fly Part 2

1. Teaching Clinical Reasoning On the Fly Part 2 David Gary Smith, MD, FACP Internal Medicine Residency Director Abington Memorial Hospital

2. First Day, First Case… • Learner- very nervous PGY1 presenting their first ambulatory case to supervisor • First Challenge for Supervisor- • Create a safe positive environment • Have everyone take a deep breath and take their own pulse (House of God by Shem) • Learning cannot occur if anxiety, fear, low self- esteem are present

3. Start at the beginning… • With everyone calm… • Proceed with case… • PGY1- 80 yo woman with unproductive cough, moderate left sided pain which increases with inspiration, no fever, no shortness of breath, sick contact person with similar syndrome. Physical exam reveals some left posterior rhonchi

4. Gathering momentum… • PGY1- Most likely diagnosis may be viral pneumonitis but given age a chest x-ray seems reasonable. She added that the patient also believed that a viral infection was the most likely diagnosis. • Supervisor- • Nice succinct presentation (thrilled that you didn’t have to hear a twenty minute oratory) • Any other issues, red flags??? • Problems of premature closure and availability bias

5. To The Bedside…. • Group calibration • Do we agree on what we all hear, see, feel, sense? • Identify areas of confusion, disagreement • Reconciliation between presented and observed • Supervisor- cough, contact illness were similar but the pain seemed to be abdominal and less reliably related to inspiration. Exam did reveal left posterior rhonchi but also a pulsatile abdominal mass which was tender on palpation and reproduced the pain of the patient’s complaint

6. Immediate reflection • Did everyone agree with the abdominal findings? • Variability in the physical examination of the abdomen and palpation for aneurysm • Immediate attention to physical examination techniques • Required some considerable time for the PGY1 to be able to focus on what her hands were feeling and understand the meaning of the finding in this particular case • This process can never be rushed and it may take repeated visits

7. Management Discussion… • Reconciliation of Differential Diagnoses • Special attention to urgency of the new finding • Course of the Discussion • PGY1 needs to be given opportunity to “catch-up” • Midwifing the PGY1’s understanding must be a high priority for supervisor • Parallel process of caring for patient and facilitating the growth of the learner

8. On the way to the CT scan… • After wheeling the patient to the CT scanner, PGY1 and supervisor paused to reflect on “what just happened” • Always allow the learner to go first • Listen to the reflection with an open mind • Actively reinforce the insights of the learner and modify when appropriate • Internal instruction is far more effective than external if the latter is effective at all

9. Clinical Reasoning Issues… • PGY1- • Belief that ambulatory patients would have typical ambulatory complaints (viral pneumonitis more likely than leaking aneurysm) • Cough, contact illness, rhonchi were far more likely to be explained by viral infection • Violated Ockham’s Razor • Made my mind up before completing abdominal examination • Never felt an aneurysm before

10. Clinical Reasoning Issues… • Supervisor- • This was a tough case • Premature closure clearly limits what we can see to only that which confirms our initial suspicion • Clinical naiveté (having never had the experience) can also severely limit what you can see • Reinforce the importance of this reflective process

11. Case • Emergency surgery and repair that evening • Uneventful full recovery • What would have happened if she was sent home with a diagnosis of viral pneumonitis?

12. Other lessons… • Phenomenal case- thrill of making a diagnosis that can be remedied • Ownership of case- following the case from CT scanner, to admission, to OR, to recovery room, to hospital room regardless of workforce restrictions…. • Appreciate the meaning of taking care of this individual patient…

13. Group Discussion • Describe any experiences that dramatize some of the teaching points of the presentation • Discuss the importance of each of the steps in the process • Explore the barriers to accomplishing the elements herein described • Define future presentations that would deal with some of the issues identified in the presentation and discussion

14. Take Home Points • Suspend judgment and be positive • You were there once too!!! • Create a safe positive environment for learning • Always start with the raw data • Assumptions about data from Hx, PE, Lab, Consultants must be tested • Allow the learner to “think aloud” • Figure out how he thinks (metaphors, models, previous lessons etc.) • Careful reconstruction- making sense of it all • Facilitated Reflection- most critical step

15. Author Contact Information David Gary Smith Dgsmith@amh.org 215-481-4105