Teaching students to think about complexity and subtlety

Teaching Students to Think GeriatricallyD.W. Reynolds Foundation Annual MeetingOctober 24, 2011

Amit Shah, MD University of Texas Southwestern DallasCynthia Brown, MD, MSPH University of Alabama at BirminghamHouman Javedan, MD Harvard University1What 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

2Teaching 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 dangerousMultifactorial etiologies demand multifactorial solutions

3We can do betterTeaching trainees to think

4Outline for todayBackground about clinical reasoningTeaching 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)Learning Objective #1: Explain at least two basic models of clinical reasoning and how they apply to novice and advanced learners.Learning Objective #2: Explain how case based learning and uncertainty can be used as a pedagogical tool in teaching geriatric clinical reasoning and result in high quality, safe, patient-centered care.Learning Objective #3: Explain how a descriptive model of clinical reasoning may be used in the assessment of clinical reasoning.Learning Objective #4: Identify the value and relevance of explicitly teaching clinical reasoning as part of geriatric training.

5What is clinical reasoning? AKA:problem-solvingdecision-makingjudgmentdiagnostic reasoning

Major domain of clinical competence Thinking and decision-making processes that are used in clinical practice

1) Definition of clinical reasoning2) Analytic (hypothetico-deductive) and non-analytic (pattern recognition) types of clinical reasoning (Eva)3) Patient Safety: Error made with non-analytic/pattern recognition in geriatrics: subtle presentations, multi-factorial etiologies and syndromal presentations of illness.4) Geriatrics aspects of the following four areas of clinical reasoning (Wong, et al):-Hypothesis Cues (Atypical Presentation of Disease, Importance of corollary informants)-Hypothesis Refinement (Multifactorial etiologies, Syndromes, Incidence specific to age group)-Testing Threshold (Increased risk of harm from testing, goal of care, cost/benefit)-Treating Threshold (Polypharmacy/non-pharmacologic management, paucity of therapeutic evidence in advanced age groups, Individualized threshold/fluctuating threshold, importance of interdisciplinary care, and impacts of goals of care)

6Two Major Types of Clinical ReasoningAnalytic (hypothetico-deductive) What is generally emphasized in teachingBayes' theorem EBMGeneration of rules Non-analyticIllness ScriptsPattern recognitionExperienceSubconscious/automatic

Figures from: Eva KW. What every teacher needs to know about clinical reasoning. Medical Education 2004; 39: 98106

7Which is better?Non-analytic plays a much larger role in clinical care than we teachNon-analytic has not been shown to be inferiorExcessive reliance on pattern recognition can cause diagnostic errors

Want to teach students to use bothExample: 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 Instruct2000;17:433488Non-analytic TeachingCan teach illness scripts and pattern recognitionOne Model: Many cases, rapid fire methodKBIT at TCOM (Dr. Frank Papa)Pattern matching and pattern discriminationDiagnostic competence isproblem specificdisease-specificExplains why PBL/CBLs have limitationsRapid 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

9Areas of Clinical ReasoningWong et als analytical modelHypothesis CuesHypothesis RefinementTesting Threshold Treating Threshold10Geriatrically Thinking about Hypothesis CuesAtypical Presentation of DiseaseImportance of Corollary InformantsPicking up subtle clues from the environmentHome visits

11Geriatrically Thinking about Hypothesis RefinementMultifactorial etiologiesSyndromal PresentationIncidence specific to age groups

12Geriatrically Thinking about Testing ThresholdsIncreased risk of harm from testingIncreased likelihood of false positive testsPrognosticationGoals of careCost/benefit

13Geriatrically Thinking about Treating ThresholdsPolypharmacy/non-pharmacologic managementPaucity of therapeutic evidence in advanced age groupsIndividualized threshold/fluctuating thresholdImportance of interdisciplinary careImpacts of goals of care14The Novice Learner15The Old Way of Becoming An Expert

16Mismatch Between Teaching and PracticeWhat is TaughtWhat they observeStep-by-step approachesBook knowledgeEBM and Bayesian AnalysisHypothesis testingThorough/ Luxury of TimeQuick, snap judgments Wisdom ExperienceFast and Frugal or Flesh and Blood (real world)Pattern recognition and seemingly automatic retrieval from the subconsciousShortcuts

EKGsExpert flash judgmentsBlink by Malcom Gladwell17Clinical Guidelines and Cookbook MedicineGreat for simple, straightforward, typical patientNOT SO GREAT FOR GERIATRICS!Help reduce variability in clinical practice But we teach the heterogeneity of aging :Speed rate new knowledge appliedCan 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 nextClear targets / goals of treatmentSimplify things / take away the uncertaintyHeterogeneity of aging; If Youve Seen one 80 year old, youve seen one 80 year old18Problems of Novice TraineesAnalytic strategies more rigid and simplisticOver-reliance on algorithmsInability to account for uncertainty

What can we do?Teach which hypothesis cues are important in a given contextRefining hypotheses when additional data available.

19How will we teach them?New National Curriculum: POGOe web-GEMDisclaimer: 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!Here are two things you can do with Novice Trainees20POGOe web-GEM CurriculumStandardized Peer-Reviewed Curriculum34 cases in developmentAuthors from numerous institutionsLinked to AAMC CompetenciesAt the 3rd/4th year medical student level of detailHave a clerkship home to allow integration for schools without mandatory geriatrics rotationEmphasize core topics important to third year medical students in the cases clerkship home

21POGOe web-GEMs and Thinking SkillsUsing the CASUS platformSame platform used by medU (SIMPLE, CLIPP) 1.5 million cases completed to date

Clinical Reasoning Features:Hypothesis GenerationDiagnostic NetworksHypothesis RefinementThe strength of the pla22

POGOe web-GEM CurriculumExplicit focus on teaching novice trainees to think like a geriatricianSyndromal PresentationsAtypical PresentationsInterprofessional approaches to evaluation and treatmentTeaching about Cognitive ErrorsWell developed literature (from cognitive psychology) about diagnostic errorsPopularized by Dr. Jerome GroopmanExplicit teaching to novice trainees may: help to develop good thinking habitsdemystify 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.

How do cognitive errors occur?Typically not in isolationCascade of sequential cognitive mistakesMuch more common that novice trainees thinkUp to 10% of autopsies reveal a clinically relevant diagnosis that was missedMisdiagnosis occurs 15-20% of the time; about 80% are due to cognitive errorsTechnology not a solutionIncreased technology can increase misdiagnosisNegative head CT scan post- fall; banking on that and not doing a neuro exam28Types of Cognitive ErrorsOver 30-40 types of cognitive errors described in literatureCommon types of error easily taught during care of geriatric patients:Premature ClosureFraming or Diagnosis MomentumAvailabilityRepresentativeness ErrorsAttributionCommission Bias and Omission Bias29Premature Closure or FreezingOnce have something that fits you stop thinkingAlso has been called satisficing errorSatisfy + sufficeExamples in Geriatrics:Hospital patient with pneumonia who has a MIThe fracture most commonly missed is the secondDelirious patient with multifactorial etiology (stopping work-up with positive U/A and miss MI or meningitis)30Framing 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 PMHED admits this delirious patient with a UTI from the NH31Availability ErrorsChoosing 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 events32RepresentativenessRemoving a disease from differential diagnosis list because it does not match standard or usual presentationA major problem in diagnosis of patients in whom atypical presentations are common, like geriatricsHypothyroidism; Infection without fever33Commission 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 interventionOmission Bias (They are just old)The tendency towards inaction Events attributed to natural events of disease better than those related to a physicians interventionRooted in non-malfescenceGeriatrics example: overuse of medications for every symptom or excessive investigation with technology in patients with limited life expectancy34Attribution ErrorsStereotypingJudgmentalGender BiasRacial BiasAge Bias

35Teaching avoidance of cognitive errorsMake thinking explicit Think out loud!FeedbackReflective PracticeBecome comfortable with uncertainty Acknowledgement we get it wrong at least 10% and up to 20% of timeMetacognition: Cognitive Pills for Cognitive Ills

Cognitive review- a formal review at the end of the thinking process (diagnosis selection)36The Advanced Learner37What is different about the advanced learner?1- Larger non-analytic reasoning data base2- Already adopted a form of analytical model3- Due to variability of experience and graduate medical education, variability of baseline knowledge and skills1+2+3 = Adult Learner1

1. Kolb, David (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall. If medical students are adult learners by the time they are fellows they are geriatric learnersSimilarities in practicing geriatrics as in teaching clinical reasoning to advanced learners38What 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

If medical students are adult learners by the time they are fellows they are geriatric learnersSimilarities in practicing geriatrics as in teaching clinical reasoning to advanced learners39Where to Begin? Clinical Reasoning studiesThink out loud2,3Ability to communicate reasons

2 Kassirer, J.P., Wong, J.B, Kopelman R.I. (2009). Learning Clinical Reasoning. New York: Lippincott Williams & Wilkins3 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.

Can You Teach Advanced Learners? Adult Learning Curricula2Experiential learning (why, how, what, if)3Case based learningReal life application (a.k.a. relevant)Learning ObjectivesReflection4

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 Case basedReal life application

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?

UNCERTAINTYUncertainty is the result of complexity in the clinical setting (back to Hazzard)42Clinical Reasoning CurriculumTask:A validated adult learning method that incorporates recognized clinical reasoning methods targeting geriatric reasoning by using uncertainty as a core theme.

Clinical Reasoning CurriculumDesign:A case based learning formatPart of weekly didacticsIntroductory lecture describing basics of analytical and non-analytical clinical reasoningReflective session half way throughProvide copy of learning objectives with relevant list of geriatric knowledge and skills topicsProvide template of Wong model presentation PowerPoint for case presentation

Clinical Reasoning CurriculumDesign:Designated fellow will present a real clinical case encountered during rotation or NH overnight callAfter 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

Think out loud privately= whatClinical Reasoning CurriculumDesign:A representative from each group will present the reasoning behind their clinical decision to the whole groupThe presenting fellow will summarize each groups key reasons to confirm they are understood correctlyThe presenting fellow will share the outcomes of the case if knownThe presenting fellow will present the results of a literature search if any relevant evidence exists

Think out loud publicly= ifSummarizing= important cognitive taskFurther discuss application of evidence to geriatric populationLearning Objectives

TemplateHypothesis CuesWhat signs and symptoms are significant and why?Hypothesis RefinementWhat are your likely diagnoses and why?Testing ThresholdWhat tests would you request and why?Treatment ThresholdWhat treatment would you implement and why?Clinical Reasoning CurriculumHow 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 year3- The focus is on why a decision should be made not the list of options?Practice CaseMrs. MPC: 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.

PMHx:Diabetes, CAD s/p MI 2001 stent to circumflex, Moderate mitral regurgitation, Hypertension, Osteoarthritis

Social HxLives 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. Medications:Lisinopril 10mgMetoprolol ER 75mgGlipizide 5mg BIDHydrochlorothiazide 12.5mgAspirin 81mg, Tylenol prn

Allergies: NKDAPhysical ExamGen: Pleasant elderly female sitting comfortably in the chair, looks quietly at the groundVitals: P 60 regular, BP 130/70, T97.7, Sat 96% RAHEENT: no cervical lymphadenopathy, dry oral mucosaCVS: No JVP, HS: S1 + S2 + 2/6 pansystolic murmur at apex radiating to axillaResp: Sparse inspiratory crackles at both basesAbdomen: Soft, non-tender, bowel sounds present, no hepatosplenomegalyExt: 1+ edema, no cyanosis, no clubbingNeuro: CN intact, Power 4+/5 all four limbs, Reflexes difficult to elicitCognitive: Montreal Cognitive Assessment 25/30- missed last trail, missed 2 serial sevens, 2 delayed recall missed but able to recall with categorical cue, missed dateGet 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 1.4Hypothesis CuesWhat signs and symptoms are significant and why?Hypothesis RefinementWhat are your likely diagnoses and why?Testing ThresholdWhat tests would you request and why?Treatment ThresholdWhat treatment would you implement and why?Hypothesis Refinement:What are your likely diagnoses and why?AssessmentNo 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 itselfSimilar to cognitive testing => we get an overall picture without stressing necessarilyAssessmentReflection important and specifically placed at mid-way point to address concerns sooner than later

Faculty observation and participation during sessionGuided observation based on learning objectives

Faculty Observer ExamplesHow 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)

Less likely to have been exposed in depth to physiology of agingWell trained in clinical guidelines not based on elderly populationWhat CR adds to assessmentAble to observe a trainees knowledge base, communication, and cognitive style (analytical vs non-analytical). The Good StudentBe able to assess which geriatric domains are missingThe Bad StudentBe able to identify where the deficiency is in a more controlled environment ReferencesElstein 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, 2007Graber 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: 98106Kassirer, J.P., Wong, J.B, Kopelman R.I. (2009). Learning Clinical Reasoning. New York: Lippincott Williams & Wilkins

61