1. TEACH ON THE RUN! SESSION 3: HELPING LEARNERS THINK! DIAGNOSTIC REASONING Created by Dr. Leslie Ann Sadownik

2. I can be a better teacher… By Inspiring learners By Involving them By teaching them how to think By providing useful information to help them improve as clinicians.

3. 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

4. Office for Faculty Development 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.

5. In medical school we teach … Identify Problems Generate Hypothesis Explain Mechanisms Gather Data Test Hypothesis Apply to Problem Steps of PBL inquiry process

6. Office for Faculty Development ABC Educational Primer for Physicians 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.

7. Step 1: Data Gathering Interview Physical Examination Investigation

8. Office for Faculty Development 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.

9. Office for Faculty Development ABC Educational Primer for Physicians Reasoning Framework Start with an Anatomic /Physiologic Dx Generate a Differential or Pathologic Dx Arrive at a Clinical Dx Review investigations Consider factors from –History –Physical examination –Investigations Arrive at a Provisional (working) Dx

10. Office for Faculty Development 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

11. Office for Faculty Development ABC Educational Primer for Physicians Diagnostic Reasoning Review factors from History Examination Investigations Should support Provisional (working) Dx

13. The Case Presentation Practical teaching tip Teach around the traditional case presentation using practical teaching methods like the One Minute Preceptor or SNAPPS.

14. Office for Faculty Development ABC Educational Primer for Physicians One Minute Preceptor Model*

16. Practical Tip Teach the learner to present the case using SNAPPs

17. SNAPPS SummarizeNarrowAnalyzeProblePlanSelect

20. 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

21. But… how do doctors think? Analytical Non- analytical

22. Office for Faculty Development 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

23. Office for Faculty Development ABC Educational Primer for Physicians Stages of Reasoning Low knowledge Acquired knowledge –cluttered facts --- organized framework Experience –Scripts

24. Application to Teaching ? Office for Faculty Development ABC Educational Primer for Physicians

25. 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

26. Office for Faculty Development ABC Educational Primer for Physicians Reasoning Framework Diagnostic Reasoning Start with an Anatomic /Physiologic/Phenomenologic Dx Generate a Differential pathologic Dx Arrive at a Clinical Dx Review investigations Consider factors from –History –Physical examination –Investigations Arrive at a Provisional (working) Dx Therapeutic Reasoning Define the natural history of the disease Review treatment options and alternatives Consider expectations risks Decide upon a Treatment of Choice.