D.W. Reynolds Foundation Annual Meeting October 24, 2011 Amit
Shah, MD University of Texas Southwestern Dallas Cynthia Brown, MD,
MSPH University of Alabama at Birmingham Houman Javedan, MD Harvard
University Slide 2 What is a geriatrician? .as a geriatrician, I am
by definition an expert in subtlety and complexity Hazzard, W. I Am
a Geriatrician JAGS 52:161, 2004 Slide 3 Teaching with aphorisms
and pearls.. Always remember the atypical presentation of disease.
The older patient often wont have read the textbook. If youve seen
one 80 year old, youve seen one 80 year old. Occams Razor is
dangerous Multifactorial etiologies demand multifactorial solutions
Slide 4 We can do better Teaching trainees to think Slide 5 Outline
for today Background about clinical reasoning Teaching of clinical
reasoning in novice trainees (medical students) Teaching and
assessment of clinical reasoning in advanced trainees (fellows)
Clinical Reasoning Case Practice (in a small group) Slide 6 What is
clinical reasoning? AKA: problem-solving decision-making judgment
diagnostic reasoning Major domain of clinical competence Thinking
and decision-making processes that are used in clinical practice
Slide 7 Two Major Types of Clinical Reasoning Analytic
(hypothetico-deductive) What is generally emphasized in teaching
Bayes' theorem EBM Generation of rules Non-analytic Illness Scripts
Pattern recognition Experience Subconscious/automatic Figures from:
Eva KW. What every teacher needs to know about clinical reasoning.
Medical Education 2004; 39: 98106 Slide 8 Which is better?
Non-analytic plays a much larger role in clinical care than we
teach Non-analytic has not been shown to be inferior Excessive
reliance on pattern recognition can cause diagnostic errors Want to
teach students to use both Example: EKG reading teaching study
Norman GR, Brooks LR, Colle CL, Hatala RM. The benefit of
diagnostic hypotheses in clinical reasoning: experimental study of
an instructional intervention for forward and backward reasoning.
Cognit Instruct 2000;17:43348 Slide 9 Non-analytic Teaching Can
teach illness scripts and pattern recognition One Model: Many
cases, rapid fire method KBIT at TCOM (Dr. Frank Papa) Pattern
matching and pattern discrimination Diagnostic competence is
problem specific disease-specific Explains why PBL/CBLs have
limitations Rapid Fire, multiple cases have a role (eg Prognosis
app) Papa FJ, Oglesby MW, Aldrich DG, Schaller F, Cipher DJ.
Improving diagnostic capabilities of medical students via
application of cognitive sciences-derived learning principles.
Medical Education, 41:419-425, 2007 Slide 10 Areas of Clinical
Reasoning Wong et als analytical model Hypothesis Cues Hypothesis
Refinement Testing Threshold Treating Threshold Slide 11
Geriatrically Thinking about Hypothesis Cues Atypical Presentation
of Disease Importance of Corollary Informants Picking up subtle
clues from the environment Home visits Slide 12 Geriatrically
Thinking about Hypothesis Refinement Multifactorial etiologies
Syndromal Presentation Incidence specific to age groups Slide 13
Geriatrically Thinking about Testing Thresholds Increased risk of
harm from testing Increased likelihood of false positive tests
Prognostication Goals of care Cost/benefit Slide 14 Geriatrically
Thinking about Treating Thresholds Polypharmacy/non-pharmacologic
management Paucity of therapeutic evidence in advanced age groups
Individualized threshold/fluctuating threshold Importance of
interdisciplinary care Impacts of goals of care Slide 15 Slide 16
The Old Way of Becoming An Expert Slide 17 Mismatch Between
Teaching and Practice What is Taught What they observe Step-by-step
approaches Book knowledge EBM and Bayesian Analysis Hypothesis
testing Thorough/ Luxury of Time Quick, snap judgments Wisdom
Experience Fast and Frugal or Flesh and Blood (real world) Pattern
recognition and seemingly automatic retrieval from the subconscious
Shortcuts Slide 18 Clinical Guidelines and Cookbook Medicine Great
for simple, straightforward, typical patient NOT SO GREAT FOR
GERIATRICS! Help reduce variability in clinical practice But we
teach the heterogeneity of aging : Speed rate new knowledge applied
Can be good, but previous disasters with rapid adoption of untested
practice/medications in the geriatric patient (eg, Vioxx, RALES
trial, etc) Why trainees love them: Clear answer of what to do next
Clear targets / goals of treatment Simplify things / take away the
uncertainty Slide 19 Problems of Novice Trainees Analytic
strategies more rigid and simplistic Over-reliance on algorithms
Inability to account for uncertainty What can we do? Teach which
hypothesis cues are important in a given context Refining
hypotheses when additional data available. Slide 20 How will we
teach them? New National Curriculum: POGOe web-GEM Disclaimer: Both
myself and Amit Shah are involved in this initiative Teach trainees
explicitly about thinking and cognitive errors Our niche as
geriatricians, given our patients disproportionately suffer
consequences of cognitive errors! Slide 21 POGOe web-GEM Curriculum
Standardized Peer-Reviewed Curriculum 34 cases in development
Authors from numerous institutions Linked to AAMC Competencies At
the 3 rd /4 th year medical student level of detail Have a
clerkship home to allow integration for schools without mandatory
geriatrics rotation Emphasize core topics important to third year
medical students in the cases clerkship home Slide 22 POGOe
web-GEMs and Thinking Skills Using the CASUS platform Same platform
used by medU (SIMPLE, CLIPP) 1.5 million cases completed to date
Clinical Reasoning Features: Hypothesis Generation Diagnostic
Networks Hypothesis Refinement Slide 23 Slide 24 Slide 25 Slide 26
POGOe web-GEM Curriculum Explicit focus on teaching novice trainees
to think like a geriatrician Syndromal Presentations Atypical
Presentations Interprofessional approaches to evaluation and
treatment Slide 27 Teaching about Cognitive Errors Well developed
literature (from cognitive psychology) about diagnostic errors
Popularized by Dr. Jerome Groopman Explicit teaching to novice
trainees may: help to develop good thinking habits demystify
process of coming to diagnosis Croskerry P. The importance of
cognitive errors in diagnosis and strategies to minimize them. Acad
Med. 2003;78:775-780. Croskerry P. Cognitive forcing strategies in
clinical decision making. Ann Emerg Med. 2003;41:110-120.
Redelmeier DA. Improving patient care. The cognitive psychology of
missed diagnoses. Ann Intern Med. 2005;142:115-120. Slide 28 How do
cognitive errors occur? Typically not in isolation Cascade of
sequential cognitive mistakes Much more common that novice trainees
think Up to 10% of autopsies reveal a clinically relevant diagnosis
that was missed Misdiagnosis occurs 15-20% of the time; about 80%
are due to cognitive errors Technology not a solution Increased
technology can increase misdiagnosis Slide 29 Types of Cognitive
Errors Over 30-40 types of cognitive errors described in literature
Common types of error easily taught during care of geriatric
patients: Premature Closure Framing or Diagnosis Momentum
Availability Representativeness Errors Attribution Commission Bias
and Omission Bias Slide 30 Premature Closure or Freezing Once have
something that fits you stop thinking Also has been called
satisficing error Satisfy + suffice Examples in Geriatrics:
Hospital patient with pneumonia who has a MI The fracture most
commonly missed is the second Delirious patient with multifactorial
etiology (stopping work-up with positive U/A and miss MI or
meningitis) Slide 31 Framing or Diagnosis Momentum Once several
doctors/specialists agree on a diagnosis it is easier to perpetuate
it rather than take the time to question its accuracy In
Geriatrics: Chart Lore for PMH ED admits this delirious patient
with a UTI from the NH Slide 32 Availability Errors Choosing most
likely or most memorable diagnosis Over-estimation of frequency of
vivid or easily recalled events Under-estimation of frequency of
ordinary or hard to recall events Slide 33 Representativeness
Removing a disease from differential diagnosis list because it does
not match standard or usual presentation A major problem in
diagnosis of patients in whom atypical presentations are common,
like geriatrics Slide 34 Commission Bias (inability to follow
geriatric mantra: Dont just do something, stand there) Urge to act
rather than do nothing even when nothing is preferable. Rooted in
belief that beneficence involves active intervention Omission Bias
(They are just old) The tendency towards inaction Events attributed
to natural events of disease better than those related to a
physicians intervention Rooted in non-malfescence Slide 35
Attribution Errors Stereotyping Judgmental Gender Bias Racial Bias
Age Bias Slide 36 Teaching avoidance of cognitive errors Make
thinking explicit Think out loud! Feedback Reflective Practice
Become comfortable with uncertainty Acknowledgement we get it wrong
at least 10% and up to 20% of time Metacognition: Cognitive Pills
for Cognitive Ills Slide 37 Slide 38 What is different about the
advanced learner? 1- Larger non-analytic reasoning data base 2-
Already adopted a form of analytical model 3- Due to variability of
experience and graduate medical education, variability of baseline
knowledge and skills 1+2+3 = Adult Learner 1 1. Kolb, David (1984).
Experiential learning: Experience as the source of learning and
development. Englewood Cliffs, NJ: Prentice-Hall. Slide 39 What is
different about the new Geriatric learner? Less likely to be
exposed to geriatric clinical reasoning domains described at
beginning of presentation Well trained in clinical guidelines not
based on the elderly (worked hard and invested heavily in achieving
recognition for it) Less likely to have experience in a nursing
home or rehab setting Slide 40 Where to Begin? Clinical Reasoning
studies Think out loud 2,3 Ability to communicate reasons 2
Kassirer, J.P., Wong, J.B, Kopelman R.I. (2009). Learning Clinical
Reasoning. New York: Lippincott Williams & Wilkins 3 Alberdi E,
Taylor P, Lee R. Elicitation and representation of expert knowledge
for computer aided diagnosis in mammography. Methods Inf Med.
2004;43(3):239-46. Slide 41 Can You Teach Advanced Learners? Adult
Learning Curricula 2 Experiential learning (why, how, what, if) 3
Case based learning Real life application (a.k.a. relevant)
Learning Objectives Reflection 4 2 Armstrong, Liz and Kegan,
Robert. Harvard Macy Institute Curriculum for Educators. 3
Armstrong E, Parsa-Parsi R. How can physicians' learning styles
drive educational planning? Acad Med. 2005 Jul;80(7):680-4. 4 Stark
P, Roberts C, Newble D, Bax N. Discovering professionalism through
guided reflection. Med Teach. 2006 Feb;28(1):e25-31 Slide 42 What
cognitive aspect makes it specifically geriatric? If you had to
develop a Geriatric Clinical Reasoning Mini-Cog to screen for
geriatric clinical executive function what would be the clock draw?
UNCERTAINTY Slide 43 Clinical Reasoning Curriculum Task: A
validated adult learning method that incorporates recognized
clinical reasoning methods targeting geriatric reasoning by using
uncertainty as a core theme. Slide 44 Clinical Reasoning Curriculum
Design: A case based learning format Part of weekly didactics
Introductory lecture describing basics of analytical and
non-analytical clinical reasoning Reflective session half way
through Provide copy of learning objectives with relevant list of
geriatric knowledge and skills topics Provide template of Wong
model presentation PowerPoint for case presentation Slide 45
Clinical Reasoning Curriculum Design: Designated fellow will
present a real clinical case encountered during rotation or NH
overnight call After presenting the case the presenting fellow will
choose question from one of the Wong model domains The group will
then divide into groups of 2 to 3 fellows and discuss the question
for 5-10 minutes Slide 46 Clinical Reasoning Curriculum Design: A
representative from each group will present the reasoning behind
their clinical decision to the whole group The presenting fellow
will summarize each groups key reasons to confirm they are
understood correctly The presenting fellow will share the outcomes
of the case if known The presenting fellow will present the results
of a literature search if any relevant evidence exists Slide 47
Learning Objectives Slide 48 Template Hypothesis Cues What signs
and symptoms are significant and why? Hypothesis Refinement What
are your likely diagnoses and why? Testing Threshold What tests
would you request and why? Treatment Threshold What treatment would
you implement and why? Slide 49 Clinical Reasoning Curriculum How
is this different from morning report?: 1- Case must not have a
single correct answer (must include uncertainty) 2- The level of
uncertainty should increase over the course of the year 3- The
focus is on why a decision should be made not the list of options?
Slide 50 Practice Case Slide 51 Mrs. M PC: Fatigue HPC: Mrs. M, an
80 year old woman presents with her daughter, Sarah, to outpatient
clinic complaining of fatigue. She has been feeling more tired over
the last 8 months but things have gotten to a point that Sarah is
concerned. Mom is just not herself she says. Sarah says Mary is
tired all the time. She would usually go out and walk around the
block but now she only makes it to the driveway mailbox and back.
She has had no weight loss, appetite is fair, no chest pain, no
palpitations, no cough, no fever, no chills, no dysuria, no
increased urinary frequency, no change in bowel habit. Slide 52
PMHx: Diabetes, CAD s/p MI 2001 stent to circumflex, Moderate
mitral regurgitation, Hypertension, Osteoarthritis Social Hx Lives
with her daughter and son in-law. Daughter is with her 24 hours a
day. Functional history: Independent for most ADLs until 1 month
ago, now needs help with dressing and showering. Needs help with
instrumental activities of daily living for the past 3 years. Uses
cane when walking out of the house. Slide 53 Medications:
Lisinopril 10mg Metoprolol ER 75mg Glipizide 5mg BID
Hydrochlorothiazide 12.5mg Aspirin 81mg, Tylenol prn Allergies:
NKDA Slide 54 Physical Exam Gen: Pleasant elderly female sitting
comfortably in the chair, looks quietly at the ground Vitals: P 60
regular, BP 130/70, T97.7, Sat 96% RA HEENT: no cervical
lymphadenopathy, dry oral mucosa CVS: No JVP, HS: S1 + S2 + 2/6
pansystolic murmur at apex radiating to axilla Resp: Sparse
inspiratory crackles at both bases Abdomen: Soft, non-tender, bowel
sounds present, no hepatosplenomegaly Ext: 1+ edema, no cyanosis,
no clubbing Neuro: CN intact, Power 4+/5 all four limbs, Reflexes
difficult to elicit Cognitive: Montreal Cognitive Assessment 25/30-
missed last trail, missed 2 serial sevens, 2 delayed recall missed
but able to recall with categorical cue, missed date Get up and go:
failed, unable to get out of chair Labs 1 month ago: WCC 11, Hct
32, MCV 85, Plt 250, Na 132, K 4.0, BUN 24, Cr 1.4 Slide 55
Hypothesis Cues What signs and symptoms are significant and why?
Hypothesis Refinement What are your likely diagnoses and why?
Testing Threshold What tests would you request and why? Treatment
Threshold What treatment would you implement and why? Slide 56
Hypothesis Refinement: What are your likely diagnoses and why?
Slide 57 Assessment No simple validated MCQ- but is this
appropriate? How are we assessing Clinical Reasoning currently?
Rotation evaluations bring in high variability of confounding
variables if trying to hone in on clinical reasoning itself Similar
to cognitive testing => we get an overall picture without
stressing necessarily Slide 58 Assessment Reflection important and
specifically placed at mid- way point to address concerns sooner
than later Faculty observation and participation during session
Guided observation based on learning objectives Slide 59 Faculty
Observer Examples How well learner incorporates geriatric clinical
reasoning domains described at beginning of presentation?
(knowledge + skills) How large is a learners geriatric
non-analytical data base and does it grow over time? (skills)
Anxiety with regards to uncertainty (world of rule out MI)
(attitudes) Slide 60 What CR adds to assessment Able to observe a
trainees knowledge base, communication, and cognitive style
(analytical vs non- analytical). The Good Student Be able to assess
which geriatric domains are missing The Bad Student Be able to
identify where the deficiency is in a more controlled environment
Slide 61 References Elstein AS, Schwarz A. Clinical problem solving
and diagnostic decision making: selective review of the cognitive
literature. BMJ. 2002;324:729-732. Gladwell M. Blink: The Power of
Thinking Without Thinking. New York, NY: Little, Brown and Company;
2005. Groopman, Jerome E. How Doctors Think. Houghton Mifflin, 2007
Graber ML, Franklin N, Gordon RR. Diagnostic error in internal
medicine. Arch Intern Med. 2005;165:1493-1499. Croskerry P. The
importance of cognitive errors in diagnosis and strategies to
minimize them. Acad Med. 2003;78:775-780. Croskerry P. Cognitive
forcing strategies in clinical decision making. Ann Emerg Med.
2003;41:110-120. Redelmeier DA. Improving patient care. The
cognitive psychology of missed diagnoses. Ann Intern Med.
2005;142:115-120. Eva KW. What every teacher needs to know about
clinical reasoning. Medical Education 2004; 39: 98106 Kassirer,
J.P., Wong, J.B, Kopelman R.I. (2009). Learning Clinical Reasoning.
New York: Lippincott Williams & Wilkins
