Welcome back. This session we'll talk about clinical reasoning. And this is sort of the meat of what we all do, right. This is the heart of patient cares is thinking about How you take care of people and what's going on and how do you make a diagnosis? So, the irony does not escape me that we're going to do this in about a 15 minute video. [LAUGH] We'll try or at least I'll,uh, set the stage for you to help you, help other people think about their clinical reasoning skills. So I want to talk about the different scales that are involved in clinical reasoning. I want to give you some descriptors called the rhyme framework for students development as they engage in gaining their own skills for diagnostic reasoning. And give you a few techniques to support improved clinical reasoning for both tyour learners and for you as you're teaching. Okay, so what happens when we are presented with a clinical scenario? Well, we do things like, we get a history, right? We get a physical examination. We get lab studies. We get some imaging studies. And they all go into this sort of black box thing, that is our brain, or somebody else's brain. And something happens in that black box that's some sort of magic. And then wa-lla, what pops out is a diagnosis. So the challenge is to figure out what's going on in that magic box there, right? What is the diagnostic reasoning, and what's the magic that happens? So in general, You can think about, sort of, this diagnostic reasoning box containing a number of things. It's going to have all of the foundational knowledge, hopefully, so things like the epidemiology of the disease, the expected time course. What are so, the key features of a condition that would make that type of condition more probable. What are the things that you would exclude based on the key features of a condition. And what are the mechanisms of the disease. And so with time, and with experience as a clinician or as a provider of care, we all start to develop what are called illness scripts. And these illness scripts are basically a definition Of sort of what it means. Right? So if I say someone has Appendecitis many people who provide direct care can sort of bring that up in their mind. What does that look like? All right. if I were to say total parenteral nutrition. Or TPN. the Pharmacy folks and the, Doctors of Pharmacology would have a sense of what that looks like or what that means, the things that you need to consider, what are the key features that go into a TPN, Bag of administration etcetera. Okay. So those illness script actually get generated and actually sort of accrue over time. And they require exposure and they require experience. And somehow over time and with experience People become expert. And we talked a little bit before in some of the previous videos about expertise. And so really the magic happens for a learner when they can figure out how to place their knowledge silos that they've accrued by sitting in lecture halls or individually learning topics Into one box for their cognitive use. So then they can take those silos and actually put them together, so that then they can make a diagnosis. And that's what I talk about when I do clinical teaching. Is, you know, you spent two years sitting in a lecture hall, basically. And we taught you all the heart information in one bucket. And we taught you everything about the lung, and lung disease, and lung medications, and lung treatment, in a bucket. And we segregated out patient care. We talked about how do you care for people and what does postoperative surgical nursing look like and what does intensive care nursing look like it. So we talked everybody in the bucket and they've created these sort of mental models that could be very linear and the track is getting to put all those silos Into one box of diagnostic reasoning. So they can create their own illness scripts, and their own connections and understandings between all of that different foundational knowledge they possess. So what do we do when we make a diagnosis? Well, like I said we gather data right? We get history, we get a physical exam and then those basic facts, whether it's the epidemiology of the individual if it's you know, a male or a female. Or pre menopausal, post menopausal, those sorts of words trigger things for us as experts and we start to dial up all the illness scripts that may be in play as we're thinking about a patient. And we start to generate hypotheses and we're not sort of linear right, there's not just one. We actually have multi-channel thoughts going on about well, it could be this, or it could be that, or maybe it's this. And then we test our hypotheses based on the inclusion and exclusion criteria in the scripts or the illness scripts that we possess. So if we were talking about how to fix a car. Right? I actually don't have a lot of illness scripts in my mind about how to fix a car. So if I heard it Bumping, or if it was pulling to the left or, you know, if it hesitated in the morning when I tried to start it. many of you actually may have already come up with a bunch of illness scripts. You know, you may say oh, it's, it's the belt or oh, it's the spark plug. But I don't have that knowledge, and so without a foundation knowledge it can be difficult to come up with scripts. And so part of the challenge is understanding where your learners Starting what their knowledge base is and what things you can actually expect them to come up with as they gather data. Okay so I'm going to give you just a little second to also try your hand at illness scripts. So I'm going to have you step through the process of clinical reasoning. And just take you know two three minutes and we'll come right back. Okay. So the main points that I want you to take home is that, like I said earlier, knowing the age of the patient, the critical components of the history and physical, help you come up with multiple working diagnoses. And as you are working those diagnoses, you obtain clarifying labs and diagnostic studies to help you get to the diagnosis. To the concluding diagnosis. Now, expert clinicians have an automaticity about them, right? We, we listen to someone reporting on the phone to us what's happening. It's akin to sort of the tying the shoes metaphor that I used before. We can tie our shoes quickly, but our learners need to have it broken down into steps. Okay. So one way to assess how someone is moving through those steps of gaining illness scripts and gaining abilities to make clinical decisions is to sort of describe the learners skills. And Doctor Pangaro, there's the Referenced down below. Has talked about the RIME Framework, which I actually use almost all the time with my learners. And it's basically four different, sort of stages, or flow that people go through, where they start out as reporters. Where they give you the information, they gather it and they kind of just repeat it back, right? Or an interpreter who actually can take the information they get, decide what is or isn't important, give you the information, and then, answer further questions if you have. There's also the manager's step, right. Where they get the information. They interpret what it means and then sort of give you the explanation of what they should do. And finally, the sort of most advanced learner will be sort of an educator. Where not only do they know what they need to learn for themselves but they actually generate new questions and they, can teach others including patients and learners who are coming behind them. So, right, I organized it a different way for us all, same information but in the reporter phase, people gather facts, the have very reliable data that you know that when they tell you that the. Potassium was, you know, 4.2. It was 4.2. But they don't know what it means to have a potassium of 4.2, necessarily. And they just report back to you. and that can be somebody who's in an early clinical phase. So for our medical students, you know, it's usually pre clinical folks or people who are very early in their clinical years. The interpreter person however, is able to prioritize the information that they get when they take a patient history and do a physical exam. They can incorporate the data, they can discern it, and they start to develop diagnosis. So you can ask people well what do you think, you know? Why is this important? What's happening? And the next phase involves managing Or being a manager, and then they have judgment, they have clinical acumen, so they can incorporate the unique facts and specific circumstances of the patient and, come up with a more robust diagnosis, or a plan of action, right. And that may be your more mid-level resident, or even, sometimes, a senior resident. And then, finally, an educator is hopefully somebody who's a self directed learner, and can define questions. And shares new knowledge with others. And many of our chief residents, or the highest level learner that we have is somebody who does that. Who acts as a resource for people who are more novice. And who sort of challenges us as attendings, or as instructors. You know? Well, what does that mean? Why are you using that information? I just read this study that says this. How come you're not doing it this way? so this is the RIME framework. And I try to get people when I'm in a clinical scenario to basically move from the reporter to the interpreter phase. And so, and we've talked before in one of the other videos about the one minute preceptor, which is actually something you can do as an instructor. To help the person the person think through the information. So just a quick review, you can get a commitment from them about what they think is going on. You can ask them for the supporting evidence, so what in your history or physical or the lab data makes you think that it's this or that. You can take time to teach a big ticket item or general rule about the patient. Can reinforce the things they did well and provide constructive feedback. So that's sort of from our side of the house right? But what can the learner do actually? How can we teach our learners to engage in a thoughtful process around learning how to accrue illness script so that they can be a better diagnostician. So the learner can use something called SNAPPS, and that's an acronym. The reference is at the bottom there. It basically stands for summarizing, so the learner summarizes the information that they've obtained. They narrow the differential and give you a few options that they're thinking about. They then analyze the differential and say, well, it could be this or it could be that, and given the data that I have, I think it's this, or I think it's that, but then they probe for uncertainty, so this is all learner generated, right. The learner comes back to the room and says to you I'm seeing this patient who is 42 and has this and that and the other thing, and based on these labs and my physical findings I think it's one of these three things. I can weight my three differentials because of why I think these labs mean one thing or the other. But I'm really not sure if we need something else or if this lab means something that it should and I'm not familiar with that, right? And then the next P is for planning the next steps in the management so that they cal tell you," Well, if I think it's this diagnosis, then I want to do this; if I think it's the other diagnosis, then we should do this. " Okay? And then the last piece of the SNAPPS, s-n-a-p-p-s, is to select a case-related issue for self-study. So they actually have a medicognative moment about what's my learning opportunity, where's my gap in my knowledge and what can I read about moving forward? So, how can a learner coming to you, using snapps, actually help you teach? So this is my interpretation of what I think, okay. When a learner comes back in, it sort of summarizing things for you. You can get a sense of whether or not that learner connected enough. Information, or whether there was appropriate information. Right? So you can, in some ways, get into sort of how they were thinking. You can discern sort of how they constructed the differential. Are there really key pieces of the differential that they've missed? Have they missed a differential that will actually kill somebody if they don't think about it? Right? And the most important thing that, I think, is that there are questions Sort of where they're trying to analyze things and actually identify their zone of proximal development for you so you know where their knowledge base is. You know where their gaps are. And you can teach to that gap. You can help them jump through that gap as opposed to sort of wasting busy clinic time thinking about all the things, you know, This is the differential diagnosis for somebody who comes in with this. No, no, no, have them do that work for you. And have them come back to the room and say well it could be this differential or that and this is why I think of it. And if they've missed a key point, then you can focus on that and moving through their zone of proximal development. So these I think three sessions in this unit have talked about skill development in our learners. So we talked about simulation. We talked about teaching with data. And just a brief thing about clinical reasoning. as you know, there are multiple textbooks and sessions and classes and everything else on the internet. and in your own environment, I'm sure, talking about each of those things. But hopefully we've created a broad, Picture here to help, again, help you hone in on what works in your environment. So the next unit coming up will still be about one more domain, which is the attitudes and attributes, and how do we help teach that. Thanks again, and I'll see you soon.
