Constructing Clinical Reasoning Skills Using a Problem-Based Learning Prototype

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Constructing Clinical Reasoning Skills Using a
Problem-Based Learning Prototype
MCG-VAMC Psychology Residency Consortium

• P. Alex Mabe, Ph. D.
• Professor
• Department of Psychiatry and Health Behavior
• Medical College of Georgia

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Workshop Objectives

• Examine the domain of clinical reasoning.
• Provide an overview of Problem-Based Learning
  models in teaching clinical reasoning.
• Present an adaptation of Problem-Based Learning
  designed to teach clinical reasoning to
  predoctoral interns/residents.

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Acknowledgement

• Nettie Albrecht, Ph.D.
• Co-Creator/Co-Director of the Diagnostic/Treatment
  Seminar - PBL
• VAMC Training Director for the
• MCG-VAMC Psychology Residency Consortium
• Staff Psychologist, VAMC of AugustaAssistant
  Clinical Professor of Psychiatry, MCG

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Disclaimer
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Components of Clinical Expertise

• Experts
• Experts recognize meaningful patterns and
  disregard irrelevant information, acquire
  extensive knowledge and organize it in ways that
  reflect a deep understanding of their domain,
  organize their knowledge using functional rather
  than descriptive features, retrieve knowledge
  relevant to the task at hand fluidly and
  automatically, adapt to new situations,
  self-monitor their knowledge and performance,
  know when their knowledge is inadequate, continue
  to learn, and generally attain outcomes
  commensurate with their expertise. (p.276)

APA Presidential Task Force on Evidence Based
Practice (2006) Evidenced-based practice in
psychology. American Psychologist, 61, 271-285.
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Components of Clinical Expertise - continued

• (a) assessment, diagnostic judgment, systematic
  case formulation, and treatment planning
• (b) clinical decision making, treatment
  implementation, and monitoring of patient
  progress
• (c) interpersonal expertise
• (d) continual self-reflection and acquisition of
  skills
• (e) appropriate evaluation and use of research
  evidence in both basic and applied psychological
  science
• (f) understanding the influence of individual and
  cultural differences on treatment
• (g) seeking available resources (e.g.,
  consultation, adjunctive or alternative services)
  as needed
• and (h) having a cogent rationale for clinical
  strategies.
• (p. 276)

APA Presidential Task Force on Evidence Based
Practice (2006) Evidenced-based practice in
psychology. American Psychologist, 61, 271-285.
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Components of Clinical Expertise - continued

• competence is "the habitual and judicious use of
  communication, knowledge, technical skills,
  clinical reasoning, emotions, values, and
  reflection in daily practice for the benefit of
  the individual and community being served"
  (Epstein Hundert, 2000,p. 227). They further
  asserted that competence depends on habits of
  mind, including attentiveness, critical
  curiosity, self-awareness, and presence. (p.775)
• As such, competence connotes the capability of
  critical thinking and analysis

Kaslow NJ (2004) Competencies in professional
psychology. American Psychologist, 59, 774-781.
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Conclusions

• Clinical reasoning is a core competency of
  professional psychologists.
• Teaching clinical reasoning appears to be a
  complex task.

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How Psychologists Think

• Thinking like a psychologist is based on a
  combination of factors including
• (a) critical thinking and logical analysis
• (b) being conversant with and utilizing
  scientific inquiry and professional literature
• (c) being able to conceptualize problems and
  issues from multiple perspectives (e.g.,
  biological, pharmacological, intrapsychic,
  familial, organizational/systems, social,
  cultural)
• and (d) being able to access, understand,
  integrate, and use resources (e.g., empirical
  evidence, statistical approaches, technology,
  collegial consultation).
• (p. 369)

Elman NS, Illfelder-Kaye J, Robiner WN (2005)
Professional development training for
professionalism as a foundation for competent
practice in psychology. Professional Psychology
Research and Practice, 36, 367-375.
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Teaching Psychologists How to ThinkIts a
daunting task!
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Critical thinking and Clinical Reasoning

• Critical thinking actively and skillfully
  conceptualizing, applying, synthesizing and
  evaluating information
• Clinical reasoning all that plus have a
  knowledge of illness, illness scripts,
  illness trajectories, etiology as well as
  description, and the integration of problem
  understanding with problem solution.

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Research Regarding Diagnostic Reasoning

• Success in diagnosing one problem has been shown
  to be a poor predictor of success in diagnosing
  another.
• Content specificity has been critical in
  successful diagnostic reasoning.
• Pattern recognition appears to be key to
  diagnostic efficiency and accuracy.

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Research Regarding Diagnostic Reasoning the
development of clinical reasoning

• Expertise is not a matter of acquiring some kind
  of general, all inclusive reasoning strategy.
• Knowledge counts no one kind of knowledge
  counts more than any other.
• Expertise (in medicine) is derived from both
  formal and experiential knowledge.
• The process of pattern recognition so
  characteristic of an experts approach appears
  to be a product of extensive experience with
  patients overlaid on formal knowledge structure.
  

Geoffrey N (2006) Building on experience The
development of clinical reasoning. The New
England Journal of Medicine, 355, 2251-2252.
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General Training Recommendations The
Development of Clinical Reasoning

• Encourage students to use both analytical rule
  knowledge and experiential knowledge.
• Provide clinical reasoning experience. A critical
  element of becoming an expert is accruing the
  experience that enables experts to recognize
  patterns.
• Help students make the connection between basic
  science and specific clinical encounters.

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Elements of the Clinical Reasoning Process

• Data acquisition.
• Data organization.
• Data abstraction.
• Hypothetico-deductive method experts produce
  better hypotheses.
• Schema development.
• Illness scripts.

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Elements of the Clinical Reasoning Process-
continued

• Case formulation
• Comprehensive.
• Precise.
• Integrated.
• Coherent.
• Systematic
• Goodness-of-fit (problem definition and
  treatment)

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Elements of the Clinical Reasoning Process-
continued

• Self-monitoring skills.
• Effective use of available resources.
• Evidence based practice.
• Information management.

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Teaching Clinical Reasoning-Criticisms of
Traditional Teaching Methods

• Information overload.
• Passive transfer of expert knowledge.
• Emphasis on knowledge as opposed to skill and
  attitudes.

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Teaching Clinical Reasoning-Adult Learning

• Adults have a foundation of life experiences and
  knowledge.
• Adults are goal directed.
• Adults are relevancy-oriented.
• Adults must be shown respect.

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Problem Based Learning (PBL)

• Problem-based learning (PBL) is a method of
  teaching first adopted in undergraduate medical
  education by McMaster University in the
  mid-1960s.
• Currently, more than 90 medical schools worldwide
  have incorporated some form of PBL in their
  undergraduate curricula.
• Studies have shown that PBL can be a more
  successful approach compared with more
  traditional curricula with regard to
• intrinsic motivation
• improving problem-solving skills/clinical
  reasoning
• long-term retention of learned knowledge

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Common Components of PBL Instruction

• Small group instruction.
• A gradually evolving clinical problem is
  presented.
• Think out loud strategies are employed.
• Discussion and clinical reasoning are primarily
  self-directed although facilitators are present
  to assist.
• Identification of learning issues.
• Summarizing what has been learned.

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Aims of PBL Instruction

• Activation and elaboration of prior knowledge.
• Acquisition and integration of scientific and
  clinical knowledge.
• Restructuring prior knowledge.
• Developing clinical reasoning in context.
• Triggering curiosity and habits of lifelong
  learning.

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PBL InstructionThinking Out Loud

• What do you know?
• What do you need to know?
• Why do you need to know?
• What are your hypotheses?
• What are your learning issues?

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PBL InstructionContent Material Selected

• Often part of a core curriculum in integrating
  basic and clinical sciences.
• Paper based scenarios are more common because of
  the consistency of material presented.
• Levels of difficulty/complexity often are
  progressively introduced.

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PBL InstructionAn Unfolding Case

• Bridget is a 14year-old, biracial adolescent who
  initially presents with Major Depressive Disorder
  with Psychotic Features, but subsequently
  develops a manic episode, changing her diagnosis
  to Bipolar Disorder. She has multiple risk
  factors for suicide, and many attempts. She is
  also very sensitive to medication, and goes
  through trials of multiple antidepressants and
  mood stabilizers. She is hospitalized when she
  takes an overdose of her mother's triiyclic
  antidepressants. (p.150)

Zisook S, Benjamin S, Balon R, Glick R, Louie A,
Moutier C, Moyer T, Santos C Servis M (2005)
Alternative methods of teaching
psychopharmacology. Academic Psychiatry, 29,
141-154.
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PBL InstructionAn Unfolding Case- continued

• After obtaining consent from Bridget and her
  family, you begin to treat Bridget with
  carbamazepine and haloperidol. The family is
  actively involved in family therapy. Five days
  later in report, the nursing staff informs you
  that Bridget has developed a pruritic rash. When
  you evaluate this, you discover an erythematous,
  macutopapular eruption on the trunk
  andextremities. (p.150)

Zisook S, Benjamin S, Balon R, Glick R, Louie A,
Moutier C, Moyer T, Santos C Servis M (2005)
Alternative methods of teaching
psychopharmacology. Academic Psychiatry, 29,
141-154.
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PBL InstructionAn Unfolding Case- continued

• Bridget is very upset about the rash and accuses
  you of causing it. She subsequently begins to
  refuse all scheduled medication despite your best
  efforts to address her concerns. Her behavior and
  thought processes remain disorganized and she is
  constantly disruptive on the unit. Her parents
  are quite worried and ask you why don't just make
  her take the medications since you hove their
  permission to give them and since Bridget is an
  involuntary patient. (p.150)

Zisook S, Benjamin S, Balon R, Glick R, Louie A,
Moutier C, Moyer T, Santos C Servis M (2005)
Alternative methods of teaching
psychopharmacology. Academic Psychiatry, 29,
141-154.
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PBL InstructionHow well has it achieved its
aims?

• PBL students do as well as lecture-based learning
  counterparts on knowledge acquisition.
• PBL students tend to perform better on measures
  of reasoning and learning strategies.
• Increased use of learning resources and more
  reading for meaning.

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Challenges in Using PBL for Training
Professional Psychologists

• Psychological problems are highly complex.
• Problems are often poorly defined, and presented
  in a confusing and contradictory manner.
• Etiology of problems are multi-determined and
  often not well understood.
• Instruction time for the content that needs to be
  taught is limited.

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Our PBL Prototype for Internship Training

• Components of traditional PBL that are
  maintained
• Small group instruction.
• A gradually evolving clinical problem is
  presented.
• Think out loud strategies are employed.
• Identification of learning issues.
• Summarizing what has been learned.

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Our PBL Prototype Modifications of traditional
PBL

• The unfolding case is presented in the form of
  videoed interviews plus additional case/
  psychological assessment information.
• Guided discovery is emphasized, and in addition
  to facilitators the case expert is present and
  assists in case discussion and formulation.

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Our PBL Prototype Modifications of traditional
continued

• When learning issues are discovered, the
  facilitators guide the students in regard to
  sources of expertise that might be available.
• Processing of the case discussion is emphasized
  each session in order to encourage an attitude of
  reflection.
• Case conceptualization is emphasized and
  routinely practiced.

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Our PBL Prototype Modifications of traditional
continued

• Expert critiques of the case conceptualization
  are provided.
• PBL is followed by didactics on the knowledge
  base needed to understand and treat the patient
  problem(s) at hand.

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Case Demonstration

• 13 year-old presents with her mother.

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What you know?

• Relevant versus irrelevant data.
• Distinguishing between data versus inference.
• Organization of the data to facilitate a
  biopsychosocial examination of the data at hand
  and to facilitate recognition of schemas and
  illness scripts.

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What you know?Progression with PBL
Training-First Module to the Most Recent Module

• What we know? first session 15 y.o white male
• Lives with mother/father and 12y.o. sister
• Problems 1st noted in K.
• Previous Meds. Ritalin Prozac
• History of oppositional behavior and low
  frustration tolerance (crying and kicking the
  walls)
• Behavior problems seem situationally specific
  (only with parents)
• Dx of ADHD in special ed.
• Emotional problems, dysgraphia
• Mom-Pts Perceptions skewed, no hallucinations.
• Current medication Abilify
• In therapy for 5 years, but not currently.
• Participated in the CARE program intensive otpt
  intervention.
• Fathers belief pt is faking sometimes and
  has serious meltdowns.
• Treatment for depression with Prozac
• Participates in several activities with church.
• Not oppositional in settings where parents are
  not present.
• Avoidance and lack of motivation.
• Motivation concerns minimal efforts on homework,
  no extra work or chores.
• Exhibits kicking.

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What you know?Progression with PBL Training

• What we know? Second session -15 year old white
  male
• Peer / Family Relations
• Friends are younger, not intimate, no strong
  preferences.
• Mom and Dad Pt upset by parental
  control/structure.
• Different parental perceptions
  overstimulated versus getting his way, try to
  accommodate to decrease tension.
• Sister- pt bullies her, physically rough with
  her, but is crazy about her.
• Symptoms
• Fixation on specific clothing, rigidity only
  will watch certain TV channels.
• Avoidance of novel situations, persistent crying
  to mild stressors.
• Low frustration tolerance.
• In attention inner hyperactivity reports
  difficulty paying attention
• Social anxiety has difficulty speaking in front
  of groups, gets nervous around others, fearful of
  embarassing himself, shy with girls.
• Feels sad, tired, fearful of break-ins, Worried
  that others are mad at him.
• Scared of a spooky chapel,
• Thinks he is a weakling.
• Has lots of negative self-perceptions.
• Has a hard time enjoying things.

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What you know?Progression with PBL Training

• What we know? 13-year old with Eating Disorder
  - 1st session
• Demographic Info
• 13 y.o. cauc female, presents with her mother.
• 53 102 lbs.
• 1 sister 11 y.o.
• Symptoms/Presenting Problem
• Mom thinks I throw up too much. Made me come.
• Current weight 102 lbs./low adolescent wght
  95-96 lbs.
• Binges 2x/wk, purges 2x/day, chews/spits
  foods- occasionally.
• Denied laxative /diet pill use. Pt knows her
  symptoms anger mom.
• Restricting diet x2 years no high fat/high
  calorie
• Body Image ideal weight is 95 lbs, stomach too
  poochy, satisfied with rest of body.
• Irregular menstrual cycles,
• Difficulty distinguishing hunger from satiety,
  eats when bored not when anxious (will get sick)
• Wears baggy clothes.
• Has a temper throws tantrums.
• Medical/Psychiatric History Trauma History

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What you need to know?Inquiry based on
hypotheses, schemas, and illness scripts

• Emphasis is on inquiry that is data driven not
  just a question that you would routinely ask.
• Focuses on relevant inquiry guided by
  hypothetico-deductive reasoning, schema
  development, and/or illness scripts.
• Can develop precision in the questions that are
  being asked of the patient.

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What you need to know?Progression with PBL
Training

• What you need to know? first session-
• 15 y.o white male
• What does moms statement that the patients
  perceptions are skewed mean?
• Why therapy stopped at age 10?
• When was the cognitive testing done and why?
• How does he function well in other environments
  but not at home?

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What you need to know?Progression with PBL
Training

• What you need to know? second session 15 y.o
  white male
• Is the patients disruption because of loss of
  friendship versus disruptions in routine?
• Skewed perception difficulty with social
  cues, interpretation, or poor judgment in
  general?
• Are there weird obsessions? Preoccupation with
  restricted focus? Any repetitive or
  stereotypical behaviors?
• What is inner hyperactivity is it racing
  thoughts or obsessional thinking?

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What you need to know?Progression with PBL
Training

• What you need to know -13-year old with Eating
  Disorder- 1st session
• What is the relationship between mood and eating
  behavior?
• Why is treatment being sought now? (was 95 lbs
  but now is 102 lbs)
• How is the eating behavior affecting functioning/
  interference with life?
• What family dynamics were associated with the
  onset of symptoms? (conflict resolution style? Is
  Mom permissive? Wheres dad? How is parental
  involvement/control connecting to the eating
  behavior?)

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Why do you need to know? Think Out Loud
Reasoning

• Forces the learner to articulate the hypothesis
  or theory underlying inquiry.
• Sets up the opportunity for analyses that either
  confirm or disconfirm the hypothesis or theory.

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Why you need to know?Progression with PBL
Training

• Why you need to know? -first session-
• 15 y.o white male
• What does moms statement that the patients
  perceptions are skewed mean? Could determine
  differential diagnoses such as psychotic versus
  anxiety versus cognitive deficits versus poor
  judgment.

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Why you need to know?Progression with PBL
Training

• Why you need to know? -first session-
• 13-year old with eating disorder
• What is the relationship between mood and eating
  behavior? Could help to identify triggers/
  patterns and establish a functional analysis of
  the disordered eating behaviors.

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What are your hypotheses?

• Functional or etiological theories/models are
  encouraged and not just DSM-IV descriptive
  diagnoses.
• Requires understanding of the etiological factors
  of illness or problem, familiarity with
  descriptive diagnosis criteria, knowledge of
  illness trajectories and probabilities, and
  consideration of treatment options.

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What are your hypotheses?Progression with PBL
Training

• What are your hypotheses? -first session-
• 15 y.o white male
• Differing perspectives between the mom and dad
  cant help it versus he can
• Ruleout
• Aspergers Disorder
• OCD
• Schizoaffective Disorder

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What are your hypotheses?Progression with PBL
Training

• What are your hypotheses? -first session-
• 13 year old with eating disorder
• Ruleout
• Eating Disorder, N.o.s. versus Bulimia
• Anxiety Disorder
• Medical Condition (stomach)
• Eating Disorder may be attention seeking because
  of her sisters extensive illness

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Learning Issues

• Learning issues will vary by the case material.
• Often the facilitators have to push for greater
  awareness of learning issues.

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Learning Issues

• 15 y.o white male
• Are the dosing of medication normal?
• What is Abilify and what is it used for?
• What are the implications of dysgraphia?
• 13 year old with eating disorder
• How is a growth chart used in the diagnosis of
  eating disorders in adolescents?
• What is Total Anomalous Pulmonary Venous
  Rtn/Connection the sisters congenital medical
  condition and what would its implications be
  for her functioning and prognosis?
• What family system terms would be used to depict
  this family?

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Processing the Case

• Reflections on the case.
• Reflections on ones response to the case.
• Reflections on ones skill in processing the
  case.

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Questions and Discussion