1. Clinical reasoning tests Mitra Amini MD MPH Associate professor of SUMS

2. Patient Management Problem (PMP) Key Feature (KF) Script Concordance (SC) Clinical Reasoning Problem (CRP) Extended Matching (EM) Comprehensive Integrative Puzzle (CIP) Symptom Pool (SP)

3. Patient Management Problem This is a test of clinical problem solving skill which resemble clinical situation A PMP is usually begins with a clinical statement concerning the presenting problem of a patient with a brief history and examination data

4. It is structured in stages; at each stage the student is asked to make a decision about patient management, which he/she considers appropriate to the situation

5. Once a decision is made, further hidden information is revealed indicating the results of the proposed action He/she then bases his/her further decisions on the results revealed

7. Mrs Pamela Thompson aged 31 years, presents at your office complaining of diarrhea which has been intermittently present for the past three months. you have easy access to hospitals, specialists and laboratory facilities

8. Proceed to section A and select what action you would take first Section A: Take detailed history Perform detailed physical examination

9. Take brief history while making rapid assessment of patient Perform rapid preliminary assessment Perform office investigation Give emergency treatment Call in consultant

10. Key feature Not all steps in resolution of a problem are of equal importance and the testing time would be better spend by focusing on the critical aspects,key feature A key feature is defined as a critical step in resolution of a problem

13. Script Concordance According to script theory, clinicians mobilize networks of organized knowledge, called "scripts", to process information and progress toward solutions to clinical problems.

14. For example an ear, nose and throat specialist working with an outpatient suffering from vertigo is focusing on his or her knowledge of vertigo- inducing illnesses. As soon as a new patient comes into the room, complaining of a cervical mass for instance, the vertigo knowledge is "washed out" and networks of knowledge related to cervical masses are called to mind with direct questions to ask, physical exams to do or investigation/treatment options to decide on.

15. These knowledge networks are acquired during clinical training and refined with each clinical encounter. They are specifically adapted to the tasks clinicians commonly perform.

16. Health professionals progress toward solutions to clinical problems with hypotheses (or management options) and their related knowledge networks (scripts) in mind. They actively use them to constantly make judgments on the effect that each new piece of information has on the status of the hypothesis or option

17. Script concordance testing (SCT) is based on the principle that the multiple judgments made in these clinical reasoning processes can be probed and their concordance with those of a panel of reference experts can be measured. This provides a tool for assessing clinical reasoning

18. Scenarios are followed by a series of questions, presented in three parts. The first part ("if you were thinking of") contains a relevant diagnostic or management option. The second part ("and then you were to find") presents a new clinical finding, such as a physical sign, a pre-existing condition, an imaging study or a laboratory test result.

19. The third part ("this option would become") is a five-point Likert scale that captures examinees' decisions. The task for examinees is to decide what effect the new finding has on the status of the option, in direction (positive, negative or neutral) and intensity. This effect is captured with a Likert scale because script theory assumes that clinical reasoning is composed of a series of qualitative judgments

22. Clinical Reasoning problem After reading a brief history, participants should choose the most possible diagnosis Then they should choose from patient finding the most probable and the list probable findings

26. Extended Matching

28. Comprehensive Integrative Puzzle The CIP is similar to the extended matching assessment described by Case & Swanson (1993). However, it seems to appeal more to students and teachers because of the fun in building and solving a ‘matching puzzle’ (like a cross word puzzle

29. horizontal matching requires an ability to integrate among disciplines and the vertical columns depict knowledge in the various disciplines.

31. History a)A 45-year-old man arrived at the emergency room because of chest pressure, which began three hours beforehand while resting. There is no history of former illnesses for the last 28 years.

32. (b) A 28-year-old woman, in her third month of pregnancy, arrived at the emergency room because of severe shortness of breath (dyspnea). She complains of exertional fatigue from the beginning of her pregnancy, and increasing shortness of breath during the last week.

33. (c) A 25-year-old man complains of shortness of breath and dizziness on exertion.Both his grandfather and elder brother died suddenly at the age of 32 years. (d) A 75-year-old man arrived at the emergency room because of 15 minutes of chest pain and sweating, which began without any prior exertion.The patient had had a coronary by-pass operation nine years beforehand and was asymptomatic for nine years.

34. (e) A 32-year-old woman, with known congenital heart defect, was hospitalized with a three-week history of fever, malaise, night sweats and increasing shortness of breath. (f ) A 40-year-old woman, suffering for the last three weeks from flu-like symptoms, complains of continuous anterior chest pain during the last week.The pain is aggravated by inspiration, change of posture or swallowing

35. Symptom pool Forward reasoning Backward reasoning Principle of parsimony