How to demonstrate good clinical reasoning (tips for your ... · How to demonstrate good clinical...
Transcript of How to demonstrate good clinical reasoning (tips for your ... · How to demonstrate good clinical...
![Page 1: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/1.jpg)
How to demonstrate good clinical reasoning (tips for your synoptic exam)
Ros Carslake
Director of Veterinary CPD (small animal)
![Page 2: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/2.jpg)
This presentation
• Why is this important?
• What is clinical reasoning?
• Different methods of diagnostic and clinical reasoning
• Demonstrating a logical approach
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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”
![Page 4: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/4.jpg)
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”
?
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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?
![Page 6: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/6.jpg)
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”
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Why is this important?
• Feedback from examiners:
![Page 8: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/8.jpg)
Why is this important?
• Feedback from examiners:
• Failure to demonstrate and verbalise a sound and logical clinical reasoning
![Page 9: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/9.jpg)
Why is this important?
• Feedback from examiners:
• Failure to demonstrate and verbalise a sound and logical clinical reasoning
• Pattern recognition
![Page 10: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/10.jpg)
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
![Page 11: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/11.jpg)
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
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Clinical reasoning
• Undertaken by all clinicians
• Often automatic
• Cognitive process that underlies diagnosis/management of a patient’s presenting problem
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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”
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To make a diagnosis…
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To make a diagnosis…
Collection of information
(Chief complaint, disease
history, examination)
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To make a diagnosis…
Collection of information
(Chief complaint, disease
history, examination)
Diagnostic
possibilities
(problem lists,
differential
diagnoses)
![Page 17: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/17.jpg)
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)
![Page 18: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/18.jpg)
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!
![Page 19: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/19.jpg)
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!
![Page 20: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/20.jpg)
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!
![Page 21: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/21.jpg)
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
![Page 22: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/22.jpg)
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
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Diagnostic methods
• Varying degrees of complexity required
• Experience counts
• At least 6 approaches to making a diagnosis, of varying complexity
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Diagnostic approaches
• Pattern recognition
• Hypothetico-deductive reasoning
• Exhaustive method
• Problem-oriented method
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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
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Pattern recognition
• A 16-wk-old kitten, recently acquired from a cat shelter, with focal alopecia around the face.
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Pattern recognition
• A 16-wk-old kitten, recently acquired from a cat shelter, with focal alopecia around the face.
Ringworm
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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
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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
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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
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Hypothetico-deductive method
• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur
![Page 32: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/32.jpg)
Hypothetico-deductive method
• 8yo horse presenting with a 2 day history of severe diarrhoea, signs of dehydration, lethargy, grade 1/6 systolic heart murmur
![Page 33: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/33.jpg)
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
![Page 34: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/34.jpg)
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
![Page 35: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/35.jpg)
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
![Page 36: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/36.jpg)
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
![Page 37: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/37.jpg)
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
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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
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Logical case approach
• Pattern recognition
• Hypothetico-deductive reasoning
• Exhaustive method
• Problem-oriented method
In an exam situation:
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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:
![Page 41: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/41.jpg)
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
![Page 42: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/42.jpg)
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
![Page 43: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/43.jpg)
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.
![Page 44: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/44.jpg)
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.
![Page 45: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/45.jpg)
Case examples:
• Weight loss/underweight
• Vomiting
• Tachycardia
• Mild dehydration
• (mildly decreased appetite)
![Page 46: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/46.jpg)
Case examples:
• Weight loss/underweight
• Vomiting
• Tachycardia
• Mild dehydration
• (mildly decreased appetite)
![Page 47: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/47.jpg)
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
![Page 48: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/48.jpg)
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
![Page 49: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/49.jpg)
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
![Page 50: 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](https://reader030.fdocuments.us/reader030/viewer/2022040401/5e7772168b21ab4c815a60dd/html5/thumbnails/50.jpg)
Good Luck!