CONFLICT OF INTEREST DISCLOSURE STATEMENT
Teaching Clinical Reasoning
Sandra Larson PhD, CRNA, Associate Professor
I have no financial relationship with any commercial interest related to the content of this activity. RFUMS Associate Provost for Clinical Partnerships
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Learner Objectives
diagnosis
• To understand the theoretical framework used to characterize clinical reasoning
• To understand teaching strategies that develop clinical reasoning skills
• To create teaching strategies that develop and evaluate clinical reasoning.
1. A categorization task that allows health care
professionals to make predications about features of
clinical situations and to determine an appropriate
course of action (p. 182).
Acad. Med. 2000; 75:182-190
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Health profession educators
must improve training in:
• Clinical reasoning
• Teamwork
• Communication
Erin P. Balogh, Bryan T. Miller, & John R. Ball, Editors
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Dual Process Theory of Clinical Reasoning Intuition
v.
Analysis
Dual Process Theory Characteristics
Characteristic
Type I: Intuitive
Automaticity
High
Type II: Analytical
Low
Speed
Fast
Slow
Reliability
Low
High
Errors
More common
Rare
Effort
Low
High
Emotional Attachment
High
Low
Scientific Rigor
Low
High
Cognitive Control
Low
High
Evans, JS. (2008). Ann Rev Psychol, 59:255-78
Carlson, J.
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Cognitive Continuum Theory
Cognitive Continuum Theory
Intuition
Analysis
Intuition
Analysis
EXPERT CRNA
NOVICE
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SRNA
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Anesthesia pattern recognition – lacking
Intensive care pattern recognition – variable
Anesthesia content domain – lacking
Analytical reasoning training – lacking
Analytical reasoning experience – variable
Anesthesia pattern recognition – experienced
Anesthesia content domain – passed certification
Analytical reasoning training – + lacking
Analytical reasoning experience – variable
Custers, E. (2013). Acad Med, 88:1074-80
Custers, E. (2013). Acad Med, 88:1074-80
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BJA,108, 2: 229-35 (2012)
Cognitive error
Anchoring
Focus on one issue in deference other simultaneous issues
Availability Bias
Choose a diagnosis at the forefront of your brain due to a strong emotional connection
Premature Closure Quick assumption that fails to consider all possibilities
1. Thinking mistakes or thought process errors that
lead to incorrect diagnoses, treatments or both.
They are usually caused by subconscious bias or
heuristics, NOT a knowledge deficit.
Steigler, M.P. (2012). BJA, 108 (2): 229-35
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Feedback Bias
No awareness of a problem means it did not happen
Confirmation Bias
Only acknowledge data that supports your diagnosis
Framing Effect
Subsequent thinking is swayed by leading aspects of initial presentation
Commission Bias
Tendency toward action that rather than no action. Better safe than sorry
Overconfidence
Inappropriate boldness, not recognizing the need for help
Omission Bias
Hesitation to start treatment for fear of being wrong and causing harm
Sunk Costs
Unwilling to let go of a failing diagnosis or decision
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Teaching Strategies
Strategies for Teaching Clinical Reasoning
Match teaching to component
Identify the component parts Lay the groundwork
Make Clinical Reasoning Visible
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Lay the Groundwork
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Groundwork Supports Coaching
What is the MOST likely diagnosis associated with:
sudden onset III/VI systolic ejection murmur; SOB; and
JVD – in a patient who is 5 days post an untreated inferior
wall MI?
Analytical Reasoning
Bloom’s Taxonomy
A) Pleural effusion
B) Pericardial Effusion
C) Posterior papillary muscle rupture
D) Right ventricular infarct
Cognitive Bias
Dual Process Theory
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Components of the Analytical Process
Bloom’s Taxonomy
Knowledge
Chief Complaint
Data Acquisition
In-classroom
Assessment level
Identify Abnormal Findings
Context
Localize Findings
Develop Differentials (Hypotheses)
Search for Illness Scripts
Pre-classroom work
Experiences
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Diagnose
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Match Strategy to Component Part Differential Diagnosis for Increased PAP (Hypothetico‐deductive reasoning)
Differential
Diagnosis
A listing of hypotheses that may explain an abnormal variable/symptom
Illness Scripts
A listing of attributes that define an illness for the purpose of easy diagnostic retrieval. Identify discriminating feature(s) that enable the diagnosis to be rapidly ruled in or ruled out.
Discriminating Features
Defining Features
Identify semantic qualifiers from the illness script that facilitate diagnostic reasoning.
Reflection‐in‐action Student self assesses his/her thinking in real time.
Reflection‐on‐
action
Student self assesses his/her care in hind‐sight.
ETT kink
Circuit kink
Obesity
Abdominal “packing”
I/E valve malfunction
Abdominal insufflation
Mucous plug in ETT
Chest wall rigidity
Pneumothorax
Breath stacking (COPD)
Hemothorax Coughing
Endobronchial Intubation
Excessive ml/kg TV
Bronchoconstriction
Decreased ETT size
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Adapted from Bowen 2006, NEJM; 355: 2217-25
Diagnosis Script for Pneumothorax
Variable
Value
Heart Rate/Rhythm
Increases w/ pneumo expansion to V Fib
B/P
Decreases w/ pneumo expansion to PEA
SaO2
Decreases w/ pneumo expansion
ETCO2
Decreases w/pneumo expansion
PaCO2
Increases w/ pneumo expansion
ETCO2 Waveform
Obstructive pattern or Normal Pattern with Low ETCO2 Peak Airway Pres.
Increased
Lung Sounds
Absent on Affected Side; Hyperesonant to percussion
@mid‐clavicular line, 2nd
Other: +air rush w/needle decompression
have sub‐q emphysema; may have tracheal deviation and JVD
Discriminating Feature
Pneumothorax
Defining Feature
Absent
Defining Feature
(Semantic Qualifiers)
(Semantic Qualifiers)
Wheeze
Bronchospasm
Rhonchi
Mucous Plug
ICS. May Hypothetico-Deductive Reasoning
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Harasym, PH (2008). J Med Sci; 24:341-55
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Kaohsiung (2008). J Med Sci; 24:341-55
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Increased Peak Airway Pressure
Conceptual
Pulmonary
Surgery
Take Home Points
Contextual
• Teaching clinical reasoning through out the curriculum needs to be HIGH priority
• Create a culture of metacognition throughout the program of study • Teaching Strategy #1: Lay the literature based groundwork in the first quarter of the program
– Dual process/cognitive continuum theory
– Blooms Taxonomy
– Clinical Reasoning Process
– Cognitive Errors
Equipment
Inductive Reasoning
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Take Home Points
Take Home Points
• Teaching Strategy #2: Make visible each component part of the clinical reasoning process
• Teaching Strategy #3: Teach each component part of clinical reasoning with a matched strategy
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Chief Complaint
Data Acquisition
Identify Abnormal Findings
Localize Findings
Develop Differentials (Hypotheses)
Search for Illness Scripts/Algorithms
Diagnose
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Develop differential diagnoses (hypothetico‐deductive)
Conceptualize differential diagnoses (inductive)
Identify discriminating versus defining characteristics
Students develop diagnosis scripts Students develop algorithms Reflection‐in‐action
Reflection‐on‐action
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Thank you
[email protected]
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