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Clinical reasoning tests

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Clinical reasoning tests Mitra Amini MD MPH Associate professor of SUMS Patient Management Problem (PMP) Key Feature (KF) Script Concordance (SC) Clinical Reasoning ... – PowerPoint PPT presentation

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Title: Clinical reasoning tests


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

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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

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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

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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

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26
Extended Matching
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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.

30
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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
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