1. Teaching Clinical Reasoning “On the Fly” Part 1 Donald R. Bordley, M.D. Residency Program Director University of Rochester (585) 275-2874 donald_bordley@urmc.rochester.edu

2. Key Points to Remember Teach while you work –Clinical reasoning is most effectively taught as you care for patients together, not in a lecture hall or conference room Live what you teach –If you don’t “role model” sound clinical reasoning as you discuss all your patients, the students won’t think it’s really important

3. Clinical Reasoning: Steps to Success GATHER DATA CAREFULLY Define the patient’s central problem Generate and prioritize the differential diagnosis Plan your work-up based on the differential diagnosis

4. Step 1 GATHER DATA CAREFULLY All subsequent steps in the clinical reasoning process depend on: –Accurate history –Accurate physical exam –Accurate lab data (if relevant) Involve the student –Students have the luxury of time to do this well and this step can be partially delegated to them.

5. Step 2 Define the patient’s central problem –List problems –Define central problem(s) What’s in the foreground? What’s in the background? –State the central problem clearly and concisely (Foreground) in a (patient) with (background) For example: Hemoptysis in a 62 y.o. woman with an 80 pack-year smoking history

6. Step 3 Generate and prioritize the differential diagnosis –Start with a complete list: common things are common, but don’t miss high stakes diagnoses –For each possible diagnosis decide, is it: Likely? Possible and high stakes (potentially lethal or requires prompt specific therapy)? Possible and low stakes? Unlikely?

7. Step 4 Plan work-up based on differential diagnosis –Aggressively work-up all “likely” diagnoses –Aggressively work-up all “possible high stakes” diagnoses –Defer work-up of possible low stakes and unlikely diagnoses

8. Practice Case Step 1: Data Collection Mr. Jones is a 55 y.o. man who presented to the ED this afternoon after developing the sudden onset of chest pain after he had a coughing fit while mowing his lawn. The pain is constant and sharp, made worse with inspiration and associated with moderate dyspnea. Past history is positive for hypertension, type 2 diabetes, high cholesterol and seasonal allergies. Abnormal findings on physical exam: HR 120, BP 150/90, R 28, O2 sat 92% on room air. Absent breath sounds over the right chest. There is no JVD and the trachea is midline.

9. Practice Case Step 2: Define the Patient’s Central Problem Problem list –Foreground: chest pain, dyspnea, absent right breath sounds –Background: HTN, Type 2 DM, high cholesterol Central problem statement –Chest pain, dyspnea and absent right breath sounds in a 52 y.o. man with HTN, Type 2 DM, and high cholesterol

10. Practice Case Step 3: Prioritize the Differential Diagnosis Likely –pneumothorax Possible, high stakes –acute coronary syndrome Possible, low stakes –muscle tear, rib fracture Unlikely –aortic dissection, pericarditis, pneumonia

11. Practice Case Step 4: Plan Work-up Based on Differential Work up the likely diagnosis –CXR Work-up the possible, high stakes diagnoses –acute coronary syndrome - EKG Defer work-up of other possibilities

12. CXR

13. Bottom Line Teach as you work and live what you teach! Be systematic and think out loud –What are the problems? Foreground and background. –What’s the differential? Focus on likelies and high stakes possibles. –Let your differential drive work-up and management