Medical Education Theory 101 Academic Medicine 2014 Session 11 Jennifer L. Middleton, MD, MPH, FAAFP

Objectives 1.Recall what happens to history taking without a mental abstraction. 2.Describe how to use a problem representation to choose an illness script. 3.Use Bowen’s model to help struggling learners.

Bowen’s Diagnostic Reasoning (abridged) Patient’s story Accurate problem representation Data acquisition Search for & select illness script Diagnosis

Step 1: Data acquisition Based on knowledge, experience, and other contextual factors

1 st impression = mental abstraction Guides the path for the information search AKA “history taking” no mental abstraction = non-directed history-taking

45 yo M obese painful toe

6 yo F fever, sore throat

Step 2: Accurate problem representation A one sentence summary defining the specific case in abstract terms

middle aged man obese big toe pain severe, 10/10, pain sudden onset regular alcohol use Fred BMI 39 big toe hurts really bad! started suddenly drinks ½ bottle wine/day

middle aged man obese big toe pain severe, 10/10, pain sudden onset regular alcohol use

school aged child fever, sore throat, dysphagia sudden onset no cough exudate on tonsils Alicia temp 101 at home, hurts to swallow started suddently doesn’t have a cough mom saw “white stuff” on tonsils

The problem representation: transforming patient-specific details into abstract terms monoarticular acute onsetlast night recurrent happened before just the knee

Steps 3/4: Search for & select an illness script Illness scripts trigger clinical memory, making stored knowledge accessible for reasoning tell the “story” of a disease!

Problem representations connect an individual patient situation to an illness script Predisposing conditions Pathophysiology Clinical findings

age > 40 male alcohol use diuretics abnormal uric acid metabolism precipitation of crystals inflammation sudden onset severe pain single joint recurrent illness script: predisposing conditions pathophysiology clinical findings

Gout is monoarticular acute onset exquisitely tender pain in the toe of an older male who drinks and takes HCTZ caused by abnormal uric acid metabolism and precipitation of crystals in the joint. illness script: problem representation:

age 5-15 in school contagious Streptococcus pharyngeal infection tonsillar edema tonsillar exudate sudden onset severe pain fever no cough illness script: predisposing conditions pathophysiology clinical findings

Strep pharyngitis presents suddenly in school aged children with fever and severe sore throat with an absence of cough caused by group A beta- hemolytic Streptococcus. illness script: problem representation

Novices: List differential for chief complaint Experts: Compare and contrast several relevant hypotheses (illness scripts) using their problem representation

Diagnosing & addressing SkillClueDiagnosisStrategy Data acquisition Lacking important info Not IDed what is important Model acquisition Problem represen- tation DisorganizedNo experience with this dx Connect findings to your own p.r. Poor summary statement No problem representation Provide example of your s.s. Search for & select illness script Multiple dxes not prioritized No p.r. or no illness scripts Create p.r., prioritize Ddx not linked to case Can’t compare illness scripts Ask support for each dx

Activity Diagnose problem and suggest a solution from these scenarios. SkillClueDiagnosisStrategy Data acquisition Lacking important info Not IDed what is important Model acquisition Problem represen- tation DisorganizedNo experience with this dx Connect findings to your own p.r. Poor summary statement No problem representation Provide example of your s.s. Search for & select illness script Multiple dxes not prioritized No p.r. or no illness scripts Create p.r., prioritize Ddx not linked to case Can’t compare illness scripts Ask support for each dx

References Bowen JL. “Educational Strategies to Promote Clinical Diagnostic Reasoning.” N Engl J Med 2006; 355: Neher JO et al. “A Five Step ‘Microskills’ Model of Clinical Teaching.” J Am Board Fam Pract 1992; 5: Spencer J. “Learning and teaching in the clinical environment.” BMJ 2003; 326: Documentation Feb-2007-FPM.pdf Accessed Documentation Feb-2007-FPM.pdf