Teaching Clinical Reasoning On the Fly

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Teaching Clinical ReasoningOn the Fly

• Donald R. Bordley, M.D.
• Residency Program Director
• University of Rochester
• [phone] donald_bordley_at_urmc.rochester.edu

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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 dont role model sound clinical
  reasoning as you discuss all your patients, the
  students wont think its really important

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Clinical ReasoningSteps to Success

• GATHER DATA CAREFULLY
• Define the patients central problem
• Generate and prioritize the differential
  diagnosis
• Plan your work-up based on the differential
  diagnosis

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Step 1

• GATHER DATA CAREFULLYAll subsequent steps in the
  clinical reasoning process depend on
• Accurate history
• Accurate physical exam
• Accurate lab data (if relevant)

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Step 2

• Define the patients central problem
• List problems
• Define central problem(s)
• Whats in the foreground?
• Whats 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

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Step 3

• Generate and prioritize the differential
  diagnosis
• Start with a complete list common things are
  common, but dont 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?

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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

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Practice Case Step 1Data 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.

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Practice Case Step 2Define the Patients
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

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Practice Case Step 3Prioritize the Differential
Diagnosis

• Likely
• pneumothorax
• Possible, high stakes
• acute coronary syndrome
• Possible, low stakes
• muscle tear, rib fracture
• Unlikely
• aortic dissection, pericarditis, pneumonia

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Practice Case Step 4Plan 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

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CXR
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Bottom Line

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