For First Year Medical Students Clinical Reasoning For First Year Medical Students Hypothesis-Driven History-Taking Project

Goals Provide the context & rationale for HDHT project Situate the HDHT project within clinical education Explain learning objectives of the Module Show module Explain SP exercise assessment How to access? When available? SP exercise?

Clinical Reasoning Pattern recognition “Expert clinicians begin to generate hypotheses regarding the suspected illness very quickly while gathering cues and information from the patient.” Pattern recognition

I’m not sleeping very well… Clinical Reasoning “This hypothesis driven approach is a means of coping with the open-ended problem presented by a patient.” There could be several explanations…Let me get some more information from you… I’m not sleeping very well…

Clinical Reasoning ‘The function of early hypotheses, therefore, is to limit the size of the space that must be searched for solutions to the problem.’ ‘Some way of progressively constraining the size of the search space must be found or else a clinical workup could never end in the time that is actually available’

Clinical Reasoning Hypotheses transform an open problem into one with several hypothetical solutions… The goal of the interview and physical examination is to carry out a comparative evaluation of these competing ‘diagnoses’. Differential Diagnosis

Creates a Tension ! Also a Problem… “This hypothesis driven approach = means of coping with the open-ended problem presented by a patient.” Creates a Tension ! Also a Problem…

Hypothesis Driven Approach Patient Centered Approach

Patient Centered Astute Diagnostician

Clinical Reasoning Unfortunately, “Clinical educators insist that students carry out a history: Following a formulaic path Suspending, until the end, speculation on the illness in question.”

HPI Cardinal Questions Problem? Quality? Duration, time course? Intensity? Aggravating? Alleviating? Radiation? Associated Symptoms?

Unfortunately.. “Clinical educators insist that students carry out a history and a review of systems by following a prescribed path suspending, until the end, all formulations of the illness in question.” Patient: “What are you thinking?” Physician: “Oh, I haven’t started thinking yet. First I gather all the information and then I think about it.”

Clinical Reasoning “We detriment our students in the traditional training approach by teaching a scheme that is not actually the one we expect them to utilize a scant year or two later.”

Clinical Reasoning What clinicians would actually admit that such is their method of reasoning!

Hypothesis Driven History

HPI History Taking Hypothesis Driven History Module: Introduce Process Case Profiles - illness scripts Cardinal Questions: Problem Location Severity Aggravating Alleviating Radiating Assoc Sxs Cardinal Questions Pertinent +/- Year 1 Year 2 Year 3 Year 4 Normal Pathology Patient Contact Develop Skills

Hypothesis Driven History Taking Project Objectives Enhance diagnostic abilities Introduce pattern recognition Maintain Patient-Centeredness ______________________________________________________________________ Learning Module SP Exercise Quiz

Hypothesis Driven History Taking Project Module Web module: Clinical Reasoning - epistemology Diagnostic scripts & pattern Self-Assessment Questions/Answers

HDHT Timeline of Activities for Project Module Open for Study February 17, 2010 To Access Module: To be given out at lecture Feb 16th SP Encounter & Quiz March 23, 2010 (Entire Class) Module’s Web link address