Clinical Problem Solving: A student and a teacher talk about lessons learned from an online course

By Heather Murray, MD, and Eve Purdy, MD Candidate, 2015

For many medical students, the process involved in turning a presenting complaint into an appropriate and focused differential diagnosis seems like a big black box. For clinicians who do this many times every day, the process is unconscious, and it is hard to explain to medical student learners how to break it down. Both students and teachers sometimes struggle with how to transition early medical learners to competent diagnosticians.

black boxSo, when a clinician (Heather Murray) and a second year medical student (Eve Purdy) independently stumbled across the link to a Massive Open Online Course (MOOC) on Clinical Problem Solving offered through Coursera both of us jumped at the opportunity to learn more about diagnostic reasoning. Eve registered with the hope of shedding light on the type of problem solving that she might be faced with in clerkship, while Dr. Murray registered with the intention of improving her teaching around diagnostic reasoning for students.

Though it is difficult to summarize the six-week course in one blog post there were a few takeaways from the course that we will outline. These key points might help medical students improve clinical reasoning and the same tips might help teachers in clarifying the process for learners. Much of this approach to clinical reasoning comes from the NEJM article  “Educational Strategies to Promote Clinical Reasoning” by Judith Bowen (2006).

1. Organize the way you learn about diseases using Disease Illness Scripts

If you have a structured approach to the way you learn about diseases, then you will be more efficient at recalling that information and comparing diseases effectively. One way to organize information is into “Disease Illness Scripts”. This requires organizing information about the conditions into four broad categories.

Epidemiology Timing Clinical Presentation Pathophysiology
-who gets the disease?-what are the risk factors?

-making a mental picture of who you would expect to see with the disease can help

-over what time period does the condition present? 

hyperacutely: hours

acutely: days

sub-acutely:    days-months

chronic: months-years

acute on chronic

-a good way to think about this is where you would expect to see the patient (ER, vs walk-in vs family doctor)

-what are the symptoms? 

-physical signs?

*key features are signs and symptoms that are essential to the diagnosis

*differentiating signs and symptoms are those that make this disease different then diagnoses that present similarly

*excluding signs and symptoms are those that, if present, exclude the disease

-describe and understand the underlying disease mechanism

2. Organize the way you think about patients using Patient Illness Scripts

When thinking about patients try to frame their presentation using the same structure as the disease illness scripts.

Epidemiology Timing Clinical Presentation
What important risk factors does the patient have-age

-smoking

-relevant medical history

-presentation specific risk factors i.e. recent transcontinental  air travel in a patient with shortness of breath

How long has the patient had the symptoms, have they changed?  What symptoms and clinical signs does the patient have? 

-try to group as many as possible to shorten the list (e.g. group febrile, tachycardic and hypotensive as septic)

3. Compare disease illness scripts and patient illness scripts to generate a tiered differential diagnosis

Generate a differential diagnosis based on the chief complaint. You can compare your understanding about each disease on your differential with your patient using the illness scripts easily. Pay close attention to key features, differentiating features and excluding features. The closer a disease illness script is to the patient illness script the higher it should end up on your differential. Your final differential has three tiers:

Tier 1: Diseases that are those most likely belong here. The epidemiology, time course and clinical presentation are concordant with the patient illness script.

  • Tier 1e: Diseases on tier 1e are diagnoses that may be less likely than tier 1 but if missed will cause immediate and serious harm. These are dangerous diagnoses! The “e” in this tier stands for “emergency” and diseases on this list must be ruled out, even if they are less likely.

Tier 2: Diseases that have some similarities to the patient illness script but aren’t a perfect fit belong here. They are still possible but less likely than tier 1 diagnoses.

Tier 3: Diseases on your original list that do not fit the illness script. They may have excluding features or lack key features.

 4. Use your tiered differential to determine what tests to order

The tier that a possible diagnosis falls into will help you decide what tests to order to determine the final diagnosis. Think of each tier as a pretest probability.

Tier 1 diagnoses have a “high” pretest probability

  • No tests or few tests may be needed to convince you that a diagnosis in tier 1 is responsible for the patient’s presentation and similarly you would need very convincing information to take it off your list completely.
  • These and Tier 1e diagnoses should drive your initial investigations

Tier 1e diagnoses may have varying pretest probability

  • These diseases may or may not be likely but regardless tests with high sensitivity are needed to rule them out (remember “SnOUT”)

Tier 2 diagnoses have a “medium” pretest probability

  • Diseases on this tier are tricky. You really have to evaluate the sensitivity, specificity and information given from each test. You may need a few good tests get from a “medium” pretest probability to final diagnosis.

Tier 3 diagnoses have a “low” pretest probability

  • Even relatively good tests may not move diagnoses from Tier 3 up to tier 1. The positive result that you get might be due to chance. Investigating these diagnoses should be a last resort.

Gear box

These four tips won’t magically turn a medical student into an expert at clinical reasoning but they might serve to expose the way that experts think. They offer concrete ways for medical students to approach clinical reasoning and a common language for experts to discuss their approach with their learners.

For more information about MOOCs and why explicit discussion of clinical reasoning is important, see these links.

Posted on

Updated Faculty Resources Community Available

briefcaseThe newly-updated Faculty Resources Community is now available in MEdTech Central. This online resource contains great teaching and assessment ideas, highlights of Curriculum Committee, notes and slides from the retreats, and more.

The resource material available includes refresher instructions on the audio-visual equipment in teaching theatres 132 and 032 (including a map of the numbered student microphones), e-learning resources and links to the small group learning community.

This Faculty Resource Community is open to all faculty at the School of Medicine.  For more information, please contact Sheila Pinchin (sheila.pinchin@queensu.ca) or Theresa Suart (theresa.suart@queensu.ca).

Posted on

Translating students’ comments on course evaluations

Navigating students’ comments could be one of the most challenging aspects of interpreting course evaluations. In an article in Innovative Higher Education, Linda Hodges and Katherine Stanton (2007) suggest using these comments as “windows into the process of student learning and intellectual development” rather than as reviews of “how they have been entertained” by an instructor.

Hodges is Director of the Harold W. McGraw, Jr. Center for Teaching and Learning at Princeton University; Stanton is the center’s assistant director. They point out that sometimes students’ comments stem from “students’ expectations of or prior experiences with college classes” that “entail teachers standing in front of the room ‘telling.’”

For example, is a comment like “I did not learn in this class because the teacher did not teach” evidence of a lack of effective teaching, or evidence that the style of teaching – including lots of team-based work – wasn’t what the student was expecting? Reframing student comments in this light can ultimately help improve teaching, Hodges and Stanton suggest.

“We may see our evaluations less as judgments of our performance and more as insight into our students’ intellectual growth—insight that may engage us in intellectual growth as teachers and scholars.”

Hodges, L.C., and Stanton, K. (2007). “Translating comments on student evaluations into the language of learning” in Innovative Higher Education 31:279-286.

 Permalink: http://resolver.scholarsportal.info/resolve/07425627/v31i0005/279_tcoseitlol

 

Posted on