Clinical Reasoning
Hypothesis-Driven History-Taking Project
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Provide the context & rationale for HDHT project
Situate the HDHT project within clinical education
Explain learning objectives of the Module
Show module
Explain SP exercise assessment
How to access? When available? SP exercise?
“Expert clinicians begin to generate
hypotheses regarding the suspected
illness very quickly while gathering cues
and information from the patient.”
Pattern recognition
“This hypothesis driven approach is a
means of coping with the open-ended
problem presented by a patient.”
There could be several
explanations…Let me get
some more information
from you…
I’m not sleeping
very well…
‘The function of early hypotheses, therefore, is to limit the
size of the space that must be searched for solutions to the
problem.’
‘Some way of progressively constraining the size
of the search space must be found or else a clinical
workup could never end in the time that is actually
available’
Hypotheses transform an open problem into
one with several hypothetical solutions…
The goal of the interview and physical
examination is to carry out a comparative
evaluation of these competing ‘diagnoses’.
Differential Diagnosis
“This hypothesis driven approach =
means of coping with the open-ended
problem presented by a patient.”
Creates a Tension !
Also a Problem…
Hypothesis Driven Approach
Patient Centered Approach
Patient Centered
Astute Diagnostician
Unfortunately,
“Clinical educators insist that students carry out a
history:
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Following a formulaic path
• Suspending, until the end, speculation on the
illness in question.”
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Cardinal Questions
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Problem?
Quality?
Duration, time course?
Intensity?
Aggravating?
Alleviating?
Radiation?
Associated Symptoms?
Unfortunately..
“Clinical educators insist that students carry out a
history and a review of systems by following a
prescribed path suspending, until the end, all
formulations of the illness in question.”
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Patient:
“What are you thinking?”
Physician: “Oh, I haven’t started thinking yet.
First I gather all the information and then I think
about it.”
“We detriment our students in the traditional
training approach by teaching a scheme that is
not actually the one we expect them to utilize
a scant year or two later.”
What clinicians would actually admit
that such is their method of
reasoning!
HPI
Cardinal
Questions:
Problem
Location
Severity
Aggravating
Alleviating
Radiating
Assoc Sxs
Year 1
Normal
Cardinal
Questions
Pertinent +/-
Hypothesis Driven
History Module:
Introduce Process
Case Profiles - illness scripts
Year 2
Pathology
Year 3
Patient Contact
Year 4
Develop Skills
Objectives
Hypothesis Driven History Taking Project
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Enhance diagnostic abilities
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Introduce pattern recognition
Maintain Patient-Centeredness
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Learning Module
SP Exercise
Quiz
Module
Hypothesis Driven History Taking Project
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Web module:
 Clinical Reasoning - epistemology
 Diagnostic scripts & pattern
 Self-Assessment Questions/Answers
HDHT
Timeline of Activities for Project
-Module Open for Study
February 17, 2010
Module’s Web link address
-To Access Module:
To be given out at lecture Feb 16th
-SP Encounter & Quiz
March 23, 2010 (Entire Class)