9/22/14 Matching Curriculum and Expectations Clinical Reasoning & Problem Solving Diagnostic PathOinder Internet-­‐Based Program: Mechanism-­‐Based Principals of Veterinary Clinical Pathology Karen M. Young, VMD, PhD Professor of Clinical Pathology School of Veterinary Medicine University of Wisconsin-­‐Madison [email protected] Funding •  $1.24 million Learning Anytime Anywhere Partnerships
(LAAP) grant
Fund for the Improvement of Postsecondary Education
(FIPSE), US Department of Education
•  Iowa State University: Holly Bender, Jared Danielson, Pamela Vermeer, Eric Mills •  American Society for Veterinary Clinical Pathology •  University of Wisconsin: Karen M. Young •  University of California at Davis: Mary M. Christopher, Jeanne George •  University of Guelph: Darren Wood •  Veterinary Information Network: Paul D. Pion •  University of Pennsylvania: Roberta Di Terlizzi Problem-­‐solving/diagnostic reasoning process •  First 2 steps in process are: Identifying abnormalities Formulating hypotheses to explain them •  These steps are prerequisite to: Testing the hypothesis Selecting additional laboratory tests to discriminate among mechanisms 1 9/22/14 2 9/22/14 BeneOits to students •  Enjoyment •  Mastery of the language of laboratory medicine •  Mechanistic thinking: breadth and depth •  Enhanced ability to ask thoughtful and insightful questions •  Success in the core course BeneOits to students
Assessment Instruments •  The PathOinder helped students to: tie information together (connect the dots) interpret laboratory data, understanding why laboratory abnormalities occur organize their thoughts •  Immediate feedback: Value to immediate comparison of student’s path with expert’s path • Final Exam Presents laboratory data for cases Provides multiple choice questions Used to determine impact (learning) • Survey Questionnaire Used to determine usability (clarity & feasibility) and perceived impact (did they learn?) • Interviews with Faculty To determine perceived impact and usability 3 9/22/14 •  The student experience Love the immediate feedback A sense of starting to “get it” •  The faculty experience A valuable source of instructive case material Improved consistency of information taught Conclusions •  DP use seems to improve mechanism-­‐based thinking and enjoyment •  DP use is feasible for most of our learners. Improvements? Excellent resource for teaching assistants Promoted active learning BeneOits to faculty The diagnostic path -­‐ a window on the student’s thought processes and logic Confusing concepts become visible Misconceptions are discovered Focus class time on more complex or confusing concepts Focus shifted from teaching to learning Discussion with students occurs at higher levels -­‐ stimulating! BeneOits to faculty Writing the expert path leads to discovery of: New information and insights Long-­‐held assumptions One’s own misconceptions “I am improving as a clinical pathologist.” BeneOits to faculty •  Expert diagnostic path: Makes expertise public Communicates reasoning explicitly Provides vehicle to identify, discuss areas of agreement and discrepancies among clinical pathologists BeneOits to faculty •  Scholarship In deOining pathophysiologic mechanisms, gaps in knowledge-­‐base become apparent and can motivate further research. When faculty’s reasoning is explicit, scholarship is enhanced and promoted. 4 9/22/14 Multidisciplinary Approach to Teaching and Research Active Integrated Learning •  Multidisciplinary input to design solutions to complex problems is essential. Clinical Pathologists Veterinary Informaticists Instructional Systems Designers/
Evaluators Computer Scientists Acknowledgments •  Kristen R. Friedrichs Clinical Associate Professor •  Linda J. Sullivan Clinical Instructor •  Michael Collins Professor AIL Objectives 1.  Evaluate clinical cases using an explicit problem-­‐
solving process (PSP) 2.  Explain clinical manifestations of disease based on anatomy, physiology, and mechanisms of pathogenesis 3.  Discuss DDX, diagnostic plan and results, mechanisms of pathogenesis, and general treatment strategies 4.  Identify important principles learned about each case and about the problem-­‐solving process 5.  Practice efOicient & effective teamwork New Course: Active Integrated Learning (AIL) •  Year 2 students •  7 cases in each 15-­‐week semester (14 cases across both semesters) The Cases Public Health Production Med Companion Med Fall semester Spring semester Food safety Mastitis/milking hygiene Fish farm losses Feedlot deaths (3) Calf morbidity/mortality Foreign Animal Disease Canine anemia (2) Protein-­‐losing nephropathy on organic dairy farm Neurologic horse Coughing dog (3) in a dog Sick dairy cow Feline icterus (3) Inappropriate urination (4) Vomiting dog 5 9/22/14 Problem-­‐Solving Process (PSP) The Instructors Basic Science Clinical Bernard
Olsen Collins Thomas Czuprynski Vezina Jorgensen
Watters Lennix West Baan Bell Bortnowski
Cook Dreyfus
Friedrichs
Forrest Morello Pinkerton Schmidt Sullivan
Young Guests Dean Emeritus WI Vet Diagnostic Lab. State Fish Vet. State & Federal Reg. Vet. 7 Sessions / Semester 1:20 1:40
2:00
2:20
2:40
3:00
3:20
Treat/manage problem(s) Identify initial concerns/questions 3:40
4:00
4:20 Organize available information DeOinitive diagnosis Clearly state the problems (Subjective & Objective) Develop a list of hypotheses to explain the cause of the problems Interpret test results Rank/re-­‐rank the hypotheses (Assessment/ differential diagnoses) Test your hypotheses (diagnostic Plan) PSP Table: Coughing dog (pyothorax) Problems -­‐ expert Case presentation History & PE Identify problems Develop hypotheses Rank hypotheses Develop test plan Interpret tests Identify problems Re-­‐rank hypotheses Additional test plan Make diagnosis Plan treatment Consolidation Wrap-­‐up Submit Case Summary with PSP Table (UW Google doc) Prep reading & E-­‐Quiz PSP Table: Coughing dog (pyothorax) Ranked DDX -­‐ expert Pneumonia Pleural disease Cardiac disease Upper airway Thoracic neoplasm Ranked DDX – novice Blastomyces Bacteria Virus Heartworm disease Heart disease Tumor Lesson: too speciOic or too non-­‐speciOic Recommend: include an organ system or mechanism that directs testing Consolidation: explain problems in light of diagnosis (mechanisms of disease) Problems -­‐ novice Cough Weight loss Depressed Decreased exercise tolerance Tachypnea Harsh lung sounds Febrile Decr. appetite Visits Eagle River* Cough Decreased exercise tolerance Harsh lung sound Febrile Pleural effusion Nonregenerative anemia InOlammatory leukogram “Don’t know” ↓PCV Lesson: interpret ↑WBC ↑Neutrophils test results, use medical terminology ↑Lymphocytes ↑Monocytes Lesson: be complete PSP Table: Coughing dog (pyothorax) Ranked DDX expert Diagnostic Plan expert Pneumonia Thoracic rads Pleural disease (VD & lateral) Cardiac disease CBC Upper airway (EDTA) Thor neoplasm Ranked DDX novice Blastomyces Bacteria Virus Heartworm Heart disease Tumor Diagnostic Plan novice Transtrach wash Blasto Ag test Thoracic rads CBC Culture Fecal Lesson: too speciOic, too early in plan; thoracic radiographs aren’t used to diagnose “bacteria” or “virus”; culture what? 6 9/22/14 PSP Table: Coughing dog (pyothorax) Problems Ranked DDX Diagnostic Plan Cough Weight loss Depressed Decr. exercise toleran. Tachypnea Harsh lung sounds Febrile Decr. appetite Pneumonia Pleural disease Cardiac disease Upper airway Thoracic neoplasm Thoracic radiographs CBC Pleural effusion Nonreg. anemia InOlam. leukogram Pyothorax, bacterial Neoplastic effusion Chylous effusion Hemothorax Thoracocentesis Fluid cytology Septic neutrophilic exudate DX: Bacterial pyothorax Culture & sensitivity 7 Sessions / Semester 1:20 1:40
2:00
Case presentation History & PE Identify problems Develop hypotheses Rank hypotheses Develop test plan 2:20
2:40
3:00
Interpret tests Identify problems Re-­‐rank hypotheses Additional test plan Make diagnosis Plan treatment 3:20
3:40
Consolidation 4:00
4:20 Wrap-­‐up Submit Case Summary with PSP Table (UW Google doc) Prep reading & E-­‐Quiz Rubric assessment PSP: course coord. Content: lead instr. Session E-­‐survey Consolidation: explain all problems based on diagnosis Rubric
Session score: 4 to 12; Course grade: A – S – U
Session Leader Course coordinator
Excellent 3 points Satisfactory 2 points Need improvement 1 point IdentiOication of problems (problem list) All problems identiOied & concisely stated Most problems identiOied; list includes abnormalities w/o interpretation. Problem list incomplete & includes many abnormalities w/o interpretation Ranked hypothesis (ranked differential diagnoses) Appropriately detailed & adequately justiOied at each stage Too much or too little detail at each stage Not sufOiciently ranked or not justiOied Unfocused or inconsistent with current information No attempt to rank Test hypothesis Logical and (diagnostic plan) addresses top-­‐
ranked differential Acceptable, but does not address top-­‐ranked differential Unfocused and does not address differentials Mechanistic explanations of problems based on cause/ diagnosis (consolidation) SufOicient and mostly correct; Demonstrates general understanding. Few mechanisms are incorrect InsufOicient, incomplete, or incorrect. Appears copied from other sources. Through and correct Demonstrates excellent understanding Student response… 1.  … facilitate your integration of clinical presentations with mechanisms of pathogenesis, anatomy, and physiology? 2.  …enhance your abilities and conOidence in approaching clinical cases & developing differential diagnoses? 1. 2. Student response… 3.  Rate how the use of the PSP table in reference to its goals (focus efforts, consistent & uniform assessment, facilitate feedback on PSP)? 4.  Overall evaluation of the course. 3. 4. Faculty/Instructor response: Permits following progress of students through the 14 cases Team formation Promoting team work Case summary report: Google docs 7 9/22/14 Team Work Rubric Exceptional Contribute to team sessions Good Helps the team move forward by articulating the merits of alternative ideas of proposals Engages team members in ways that Facilitate the contributions of facilitate their contribu+ons to team members discussions by both construc+vely building upon or synthesizing the contribu+ons of others as well as no+cing when someone is not par+cipa+ng and invi+ng them to engage. Fosters constructive team climate Offers alterna+ve solu+on or Offers new sugges+ons to courses of ac+on that build advance the work of the on the ideas of others group Engages team members in ways that facilitate their contribu+ons to discussions by construc+vely building upon or synthesizing the contribu+ons of others. Educational Strategies Does 3 of the above. Addresses destruc+ve conflict Iden+fies and acknowledges directly and construc+vely, helping to conflict and stays engaged manage/resolve it in a way that with it. strengthens overall team cohesiveness and future effec+veness. Shares ideas but does not advance the work of the group. Engages team members in Engages team members by ways that facilitate their taking turns and listening to contribu+ons to discussions others without interrup+ng. by resta+ng the views of other team members and/or asking ques+ons for clarifica+on. Does 2 of the above. Does 1 of the above. Redirec+ng focus toward common ground, toward task at hand (away from conflict). Passively accepts alternate viewpoints/ideas/opinions. Association of American Colleges & Universities http://www.aacu.org/ to promote clinical diagnostic reasoning Acceptable Supports a constructive team climate in the following ways: 1) Treats team members respectfully by being polite and constructive in communication. 2) Uses positive vocal or written tone, facial expressions, and/or body language to convey a positive attitude about the team and its work. 3) Motivates teammates by expressing conOidence about the importance of the task and the team’s ability to accomplish it. 4) Provides assistance and/or encouragement to team members. Does all of the above. Responds to conRlict Expected 1. 
2. 
3. 
4. 
Problem representation Strategies for comparing & contrasting Providing cognitive feedback Encourage useful reading The Yellow Tabby Hepatic Prehepatic Bowen NEJM 2006 Posthepatic 8