TDG Report Illness scripts for improving clinical reasoning

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TDG ReportIllness scripts for improving
clinical reasoning

• Anna Lee, Tony Gin, Charles Gomersall,
• Warwick Ngan Kee, Gavin Joynt, Anthony Ho,
• Juliana Chan, Lex Vlantis, James Griffith,
• William Wong, Coleman Fung

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Clinical reasoning

• Involves solving medical problems in order to
  make decisions about a patients diagnosis and
  management

Groves 2002
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Key elements of the clinical diagnostic process
Patients story
Knowledge
Data acquisition
Accurate problem representation
Context
Generation of hypothesis
Search for and selection of illness script
Diagnosis
Experience
Bowen JL. NEJM 20063552219
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Development of Medical Expertise and clinical
reasoning

• Stage 1. Development of elaborate causal networks
• Learned during basic science years
• Recall facts or explain causal models of disease
  processes

Driving a car This is the steering wheel and
itThis is the brake pedal..This is a
roundabout, and at roundabouts you have to.
Schmidt et al. Acad Med 199065611-21
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Stage 2. Compilation of abridged networks

• Starts when exposed to real patients
• Knowledge gets compiled (rewritten, automated)

Diagnosing a first clinical case requires quite
a lot of mental effort and involves extensive
reasoning based on the elaborate causal networks
available to the student, but when he sees his
second or third similar case, shortcuts will
emerge. He will no longer have to activate all
possibly relevant knowledge in order to
understand what is going on in his patient only
knowledge pertinent to understanding the case
will be activated
Remember the first time you got in a car and
drove?
Schmidt et al. Acad Med 199065611-21
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Stage 3. Emergence of Illness scripts

• Based on repeated experience with patients
• Illness scripts are sufficient to diagnose and
  treat diseases

OK, you passed the driving test. Are you likely
to be over confident? Can you assess risks
quickly and accurately?
Schmidt et al. Acad Med 199065611-21
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Illness scripts
Enabling Conditions Eg. Being male, older, smoking
Fault Eg. Myocardial infarction
Consequences Eg. Profuse sweating, SOB, severe
and radiating chest pain
Van Schaik et al. J Exp Psychol 200511187-99
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Stage 4. Storing patient encounters as instance
scripts

• Based on long experience
• Physician remembers many individual patients but
  each has a different variant of the disease
• New (or newly sick) patients are
• recognized as similar to Patient X
• treated as Patient X was treated

Now youve been driving for years. Are you sure
you are up to date with the highway code? And
technically, are you sure you have picked up all
good habits (shortcuts), and no bad habits?
Schmidt et al. Acad Med 199065611-21
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Project objectives

• To develop and implement a teaching module to
  improve 4th year medical students clinical
  reasoning skills
• To assess students level of clinical reasoning
  skills

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Teaching intervention

• Rotation to 4th year Family Medicine module
• Short lecture on clinical reasoning and illness
  script theory (0.5h)
• Small group work on problem representation
  (1.5h)
• Individual guided computer work using clinical
  reasoning scenarios (1.5h)

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Example of clinical reasoning problem

• Pull down menus

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Key elements of the clinical diagnostic process
Patients story
Knowledge
Data acquisition
Accurate problem representation
Context
Generation of hypothesis
Search for and selection of illness script
Diagnosis
Experience
Bowen JL. NEJM 20063552219
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Assessment of clinical reasoning (1)

• Diagnostic Thinking Inventory
• Flexibility in thinking
• Structure of knowledge in memory
• CUHK teachers (n7)
• Flexibility in thinking (77)
• Structure of knowledge in memory (78)

Bordage et al. Med Educ 199024413-25
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Assessment of clinical reasoning (2)

• Clinical reasoning problems
• Different set of scenarios
• Students type their answers/cut and past key
  features from scenarios (spell-check features)
• Scores given to correct diagnoses and key features

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Assessing students learning outcome
Students Begin rotation Teaching package End of rotation
Intervention Diagnostic Thinking Inventory (25 min online) Clinical reasoning Diagnostic Thinking Inventory clinical reasoning scenarios on web (2 hours)
Control Diagnostic Thinking Inventory (25 min online) Self-directed learning Diagnostic Thinking Inventory clinical reasoning scenarios on web (2 hours)