Clinical reasoning tests

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Clinical reasoning tests

• Mitra Amini
• MD MPH
• Associate professor of SUMS

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• Patient Management Problem (PMP)
• Key Feature (KF)
• Script Concordance (SC)
• Clinical Reasoning Problem (CRP)
• Extended Matching (EM)
• Comprehensive Integrative Puzzle (CIP)
• Symptom Pool (SP)

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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

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• 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

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• 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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• 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

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• Proceed to section A and select what action you
  would take first
• Section A
• Take detailed history
• Perform detailed physical examination

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• Take brief history while making rapid assessment
  of patient
• Perform rapid preliminary assessment
• Perform office investigation
• Give emergency treatment
• Call in consultant

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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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Script Concordance

• According to script theory, clinicians mobilize
  networks of organized knowledge, called
  "scripts", to process information and progress
  toward solutions to clinical problems.

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• 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.

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• These knowledge networks are acquired during
  clinical training and refined with each clinical
  encounter . They are specifically adapted to the
  tasks clinicians commonly perform.

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• 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

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• 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

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• 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.

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• 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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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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Extended Matching
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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

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• horizontal matching requires an
• ability to integrate among disciplines
• and the vertical columns depict
• knowledge in the various disciplines.

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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.

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• (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.

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• (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.

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• (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

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Symptom pool

• Forward reasoning
• Backward reasoning
• Principle of parsimony