How to demonstrate good clinical reasoning (tips for your ... · How to demonstrate good clinical reasoning (tips for your synoptic exam) Ros Carslake Director of Veterinary CPD (small

How to demonstrate good clinical reasoning (tips for your synoptic exam)

Ros Carslake

Director of Veterinary CPD (small animal)

This presentation

• Why is this important?

• What is clinical reasoning?

• Different methods of diagnostic and clinical reasoning

• Demonstrating a logical approach

Why is this important?

• RCVS aims of the synoptic exam:

– Candidates are required to demonstrate competence in application and integration of learning

• RCVS marking scheme

– “Good evidence of critical judgement in selecting, organising and synthesising information to construct sound arguments.”

– “Good powers of analysis and argument”

Why is this important?

• RCVS aims of the synoptic exam:

– Candidates are required to demonstrate competence in application and integration of learning

• RCVS marking scheme

– “Good evidence of critical judgement in selecting, organising and synthesising information to construct sound arguments.”

– “Good powers of analysis and argument”

?

Why is this important?

• What do you know?

• How does that relate to this patient?

• What are you going to do next?

• Why are you going to do this?

Why is this important?

• What do you know?

• How does that relate to this patient?

• What are you going to do next?

• Why are you going to do this?

“Critical judgement”

“Analysis and argument”

Why is this important?

• Feedback from examiners:

Why is this important?

• Feedback from examiners:

• Failure to demonstrate and verbalise a sound and logical clinical reasoning

Why is this important?

• Feedback from examiners:

• Failure to demonstrate and verbalise a sound and logical clinical reasoning

• Pattern recognition

Why is this important?

• Feedback from examiners:

• Failure to demonstrate and verbalise a sound and logical clinical reasoning

• Pattern recognition

• Incomplete or poorly prioritised problem lists

Why is this important?

• Feedback from examiners:

• Failure to demonstrate and verbalise a sound and logical clinical reasoning

• Pattern recognition

• Incomplete or poorly prioritised problem lists

• Inability to give major differentials for common problems/ differentials not being ordered or logical

Clinical reasoning

• Undertaken by all clinicians

• Often automatic

• Cognitive process that underlies diagnosis/management of a patient’s presenting problem

Clinical reasoning

• Undertaken by all clinicians

• Often automatic

• Cognitive process that underlies diagnosis/management of a patient’s presenting problem

• “an ability to integrate and apply different types of knowledge, to weight evidence, critically think about arguments and to reflect on the process to arrive at a

diagnosis”

To make a diagnosis…

To make a diagnosis…

Collection of information

(Chief complaint, disease

history, examination)

To make a diagnosis…

Collection of information

(Chief complaint, disease

history, examination)

Diagnostic

possibilities

(problem lists,

differential

diagnoses)

To make a diagnosis…

Collection of information

(Chief complaint, disease

history, examination)

Diagnostic

possibilities

(problem lists,

differential

diagnoses)

Select diagnostic

tests/procedures

(interpret the

results)

To make a diagnosis…

Collection of information

(Chief complaint, disease

history, examination)

Diagnostic

possibilities

(problem lists,

differential

diagnoses)

Select diagnostic

tests/procedures

(interpret the

results)

Diagnosis!

To make a diagnosis…

Collection of information

(Chief complaint, disease

history, examination)

Diagnostic

possibilities

(problem lists,

differential

diagnoses)

Select diagnostic

tests/procedures

(interpret the

results)

Management

planDiagnosis!

To make a diagnosis…

Collection of information

(Chief complaint, disease

history, examination)

Diagnostic

possibilities

(problem lists,

differential

diagnoses)

Select diagnostic

tests/procedures

(interpret the

results)

Management

planDiagnosis!

To make a diagnosis…

Collection of information

(Chief complaint, disease

history, examination)

Diagnostic

possibilities

(problem lists,

differential

diagnoses)

Select diagnostic

tests/procedures

(interpret the

results)

Management

planDiagnosis!

Knowledge

To make a diagnosis…

Collection of information

(Chief complaint, disease

history, examination)

Diagnostic

possibilities

(problem lists,

differential

diagnoses)

Select diagnostic

tests/procedures

(interpret the

results)

Management

planDiagnosis!

Knowledge

Understanding

Diagnostic methods

• Varying degrees of complexity required

• Experience counts

• At least 6 approaches to making a diagnosis, of varying complexity

Diagnostic approaches

• Pattern recognition

• Hypothetico-deductive reasoning

• Exhaustive method

• Problem-oriented method

Pattern recognition

• Very commonly used

• Diagnosis made quickly and reflexly

• Quick and accurate when used by an experienced clinician

• Obvious disadvantages

– Limited diagnostic possibilities

– Over-reliance can perpetuate inaccurate diagnoses

– Regional differences

Pattern recognition

• A 16-wk-old kitten, recently acquired from a cat shelter, with focal alopecia around the face.

Pattern recognition

• A 16-wk-old kitten, recently acquired from a cat shelter, with focal alopecia around the face.

Ringworm

Pattern recognition

• A 16-wk-old kitten, recently acquired from a cat shelter, with focal alopecia around the face.

Ringworm

•A 14yo overweight pony with sudden onset forelimb lameness/reluctance to move

Pattern recognition

• A 16-wk-old kitten, recently acquired from a cat shelter, with focal alopecia around the face.

Ringworm

•A 14yo overweight pony with sudden onset forelimb lameness/reluctance to move

Laminitis

Hypothetico-deductive method

• Commonly used diagnostic reasoning

• Key or pivotal clinical sign or problem

• Short-list of diagnostic possibilities/hypotheses

• Test the hypotheses

– Focussed questioning, clinical exam,

• Ordered differential diagnoses list

• Select diagnostic tests accordingly

Hypothetico-deductive method

• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur

Hypothetico-deductive method

• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur

Hypothetico-deductive method

• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur

diarrhoea

Hypothetico-deductive method

• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur

• 10yo GSD presenting with a progressive RH lameness, recent decrease in appetite and perceived weight loss

diarrhoea

Hypothetico-deductive method

• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur

• 10yo GSD presenting with a progressive RH lameness, recent decrease in appetite and perceived weight loss

diarrhoea

Hypothetico-deductive method

• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur

• 10yo GSD presenting with a progressive RH lameness, recent decrease in appetite and perceived weight loss

diarrhoea

lameness

Exhaustive method

• Exhaustive history and exam

• Extensive baseline/screening testing, as far as finances allow

• Sift through data for clues

• Rare diseases/ other approaches failed

• Spurious and redundant clues

Problem-oriented approach

• Relate to both exhaustive and hyopthetico-deductive methods.

• Complete history and exam

• Key problems/signs identified and weighted

• Individual differential diagnoses lists formed

• Diagnostic testing aims to rule in/out diseases

• Repeated testing frames a diagnosis

• Ideal for complex/multiple diseases

Logical case approach

• Pattern recognition

• Hypothetico-deductive reasoning

• Exhaustive method

• Problem-oriented method

In an exam situation:

Logical case approach

• Pattern recognition

• Hypothetico-deductive reasoning

• Exhaustive method

• Problem-oriented method

• Pattern recognition

• Hypothetico-deductive reasoning

• Exhaustive method

• Problem-oriented method

In an exam situation:

So remember….

• Create a prioritised and complete problem list

• Devise a logical and prioritised DDx list

• Critically select and rationalise any tests chosen.

• Explain/reason case management decisions keeping in mind the individual case

So remember….

• Create a prioritised and complete problem list

• Devise a logical and prioritised DDx list

• Critically select and rationalise any tests chosen.

• Explain/reason case management decisions keeping in mind the individual case

Case examples:

• 14yo cat with 1 month history of weight loss and intermittent vomiting. Appetite slightly reduced.

• Exam: BCS 3/9, HR 190, normal rhythm, mild dehydration, abdominal palpation normal.

Case examples:

• 14yo cat with 1 month history of weight loss and intermittent vomiting. Appetite slightly reduced.

• Exam: BCS 3/9, HR 190, normal rhythm, mild dehydration, abdominal palpation normal.

Case examples:

• Weight loss/underweight

• Vomiting

• Tachycardia

• Mild dehydration

• (mildly decreased appetite)

Case examples:

• Weight loss/underweight

• Vomiting

• Tachycardia

• Mild dehydration

• (mildly decreased appetite)

So remember….

• Create a prioritised and complete problem list

• Devise a logical and prioritised DDx list

• Critically select and rationalise any tests chosen.

• Explain/reason case management decisions keeping in mind the individual case

So remember….

• Create a prioritised and complete problem list

• Devise a logical and prioritised DDx list

• Critically select and rationalise any tests chosen.

• Explain/reason case management decisions keeping in mind the individual case

So remember….

• Create a prioritised and complete problem list

• Devise a logical and prioritised DDx list

• Critically select and rationalise any tests chosen.

• Explain/reason case management decisions keeping in mind the individual case

Good Luck!