TEACH ON THE RUN!SESSION 3:

HELPING LEARNERS THINK!

DIAGNOSTIC REASONING

Created by Dr. Leslie Ann Sadownik

I can be a better teacher…

By Inspiring learnersBy Involving them By teaching them how to thinkBy providing useful information to help

them improve as clinicians.

Learning objectives

Compare how experts versus novices think!

Apply a framework to guide learners through the steps of diagnostic reasoning

Compare and contrast the teaching methods: One Minute Preceptor and SNAPPS

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ABC Educational Primer for Physicians

Clinical Reasoning Definition

Defines the cognitive thinking process whereby

1. a physician gathers appropriate data;

2. arrives at a diagnosis;

3. identifies a ‘treatment of choice’ and

4. gives a reasoned recommendation to the patient.

In medical school we teach …

• Identify Problems• Generate Hypothesis• Explain Mechanisms• Gather Data• Test Hypothesis• Apply to Problem

Steps of PBL inquiry

process

ABC Educational Primer for Physicians

Office for Faculty Development

Clinical Reasoning Process

• Clinical assessment of patient

Gather data

• Diagnostic Reasoning

diagnosis• Therapeutic

Reasoning

Identify a treatment

• Patient counseling

Plan

TIP! Use a Framework of Questions to Guide this Process.

Step 1: Data Gathering

Interview Physical Examination Investigation

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ABC Educational Primer for Physicians

Step 2: Diagnostic Reasoning

Practical Tip

When you have time…

Use a clinical reasoning framework to

guide your learners thru this process

when discussing patient cases.

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ABC Educational Primer for Physicians

Reasoning Framework

Start with an Anatomic /Physiologic DxGenerate a Differential or Pathologic DxArrive at a Clinical DxReview investigationsConsider factors from– History– Physical examination– Investigations

Arrive at a Provisional (working) Dx

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ABC Educational Primer for Physicians

Diagnostic Reasoning

Start with an Anatomic/Physiologic Dx

Generate a Differential/Pathologic Dx

End with a Clinical Dx

Test Hypothesis

Arrive at a provisional (working) diagnosis

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ABC Educational Primer for Physicians

Diagnostic Reasoning

Review factors from HistoryExaminationInvestigations

Should support Provisional (working) Dx

The Case Presentation

Practical teaching tip

Teach around the traditional case

presentation using practical teaching

methods like the One Minute Preceptor or

SNAPPS.

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ABC Educational Primer for Physicians

One Minute Preceptor Model*

Practical Tip

Teach the learner to present the case using SNAPPs

SNAPPS

Summarize

Narrow

Analyze

Proble

Plan

Select

Teaching around the Patient

One Minute Preceptor

Uses traditional case presentation

Preceptor initiated

Higher Order Reasoning

SNAPPS

Uses selective case presentation

Learner needs to be taught

Critical analysis

Self Assessment

But… how do doctors think?

Analytical Non-analytical

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ABC Educational Primer for Physicians

Dual Reasoning Process

Uses intuition (pattern recognition)

• diagnosis (illness/disease and instance/cases scripts)• treatment scripts

But once outside area of expertise or atypical case apply an analytical approach

Office for Faculty Development

ABC Educational Primer for Physicians

Stages of Reasoning

Low knowledge

Acquired knowledge– cluttered facts --- organized framework

Experience – Scripts

Application to Teaching ?

Office for Faculty Development

ABC Educational Primer for Physicians

Office for Faculty Development

ABC Educational Primer for Physicians

Summary

Use questions to facilitate reasoning

When you have time apply a “framework”

Teach around the case presentation (One Minute Preceptor or SNAPPS)

“think out loud” when problem solving

Office for Faculty Development

ABC Educational Primer for Physicians

Reasoning Framework

Diagnostic ReasoningStart with an Anatomic /Physiologic/Phenomenologic

DxGenerate a Differential pathologic DxArrive at a Clinical DxReview investigationsConsider factors from– History– Physical examination– Investigations

Arrive at a Provisional (working) Dx

Therapeutic ReasoningDefine the natural history of the diseaseReview treatment options and alternativesConsider

expectationsrisks

Decide upon a Treatment of Choice.