Valerie J. Lang, MD, MHPE ADGAP/Reynolds Grantee

14th Annual Meeting 10.25.16

I am not a geriatrician.

6

Does

Shows How

Knows How

Knows

Miller GE.

Clinical decision-making in context

Clinical decision-making

Clinical reasoning

Organization of knowledge

Factual Knowledge

Clinical decision-making in context

Clinical decision-making

Clinical reasoning

Organization of knowledge

Factual Knowledge

Clinical decision-making in context

Clinical decision-making

Clinical reasoning

Organization of knowledge

Factual Knowledge

Clinical decision-making in context

Clinical decision-making

Clinical reasoning

Organization of knowledge

Factual Knowledge

Clinical decision-making in context

Clinical decision-making

Clinical reasoning

Organization of knowledge

Factual Knowledge

Clinical decision-making in context

Clinical decision-making

Clinical reasoning

Organization of knowledge

Factual Knowledge

MCQ EMI

SCT EMI

MCQ

KFE SCT

MCQ Essay

Oral Exam

KFE OSCE Hi-Fi

Simulation

CSR DOCS

CASE SPECIFICITY

Performance with one clinical problem does NOT predict performance with a different problem.

≠

INTERMEDIATE EFFECT

Rewarded thoroughness > judicious data gathering

Novice Advanced Expert

Key Features • Critical step(s) to identifying and resolving clinical

problems

• Not “Key Finding” Critical piece of data used to discriminate between

diagnostic hypotheses

Key Features Exams • Canadian Qualifying Exam since 1992

• Fellowship exams, clerkships

1. Page and Bordage, 1995

Clinical problem: Gallstone pancreatitis Given a patient with risk factors for gallstones and

clinical presentation consistent with pancreatitis, the 3rd year student will:

KF1. Identify pancreatitis as the most likely diagnosis KF2. Order an ultrasound (to look for gallstones) KF3. Initiate volume resuscitation and analgesia

A 43 year old female presents with 2 days of abdominal pain and nausea. When it first began, the pain was more on her right side, and it came and went. For the past day, the pain has been more in her middle upper abdomen, and it is now constant and more intense. Her last bowel movement was yesterday and was normal. She did not vomit. She has a past hx of plantar fasciitis for which she takes ibuprofen 400mg twice a week, and hyperlipidemia for which she takes a statin every now and then. She does not smoke and drinks 1 glass wine/week. Temp 38.1, pulse 110, BP 130/80, RR 16, SaO2 99% RA. Her conjunctivae are clear. Her abdomen is obese, soft, and mildly distended. Palpation of her middle upper abdomen causes the most pain. She tenses her abdominal muscles but is able to relax them when distracted. When you press deeply in her right upper abdomen, she is able to take a full breath in. Bowel sounds are quiet.

A 43 year old female presents with 2 days of abdominal pain and nausea. When it first began, the pain was more on her right side, and it came and went. For the past day, the pain has been more in her middle upper abdomen, and it is now constant and more intense. Her last bowel movement was yesterday and was normal. She did not vomit. She has a past hx of plantar fasciitis for which she takes ibuprofen 400mg twice a week, and hyperlipidemia for which she takes a statin every now and then. She does not smoke and drinks 1 glass wine/week. Temp 38.1, pulse 110, BP 130/80, RR 16, SaO2 99% RA. Her conjunctivae are clear. Her abdomen is obese, soft, and mildly distended. Palpation of her middle upper abdomen causes the most pain. She tenses her abdominal muscles but is able to relax them when distracted. When you press deeply in her right upper abdomen, she is able to take a full breath in. Bowel sounds are quiet.

Q1. What is your leading diagnosis at this time? Select only one. A. Acute coronary syndrome B. Ascending cholangitis C. Cholecystitis D. Clostridium difficile colitis E. Gastroenteritis (bacterial) F. Gastroenteritis (viral) G. Hepatitis due to statin H. Hepatitis (viral) I. Ischemic colitis J. Mesenteric ischemia K. Pancreatitis L. Peptic ulcer disease M. Pericarditis N. Somatization O. Splenic infarction

Scoring KF1. Identify pancreatitis as the most likely Dx 1 pt K. Pancreatitis

Results Normal Normal

(SI)

WBC 18.0 4.5-11 4.5-11

Hg 13.0 11.7-16.1 117-161

Hct 39% 35-47 0.35-0.47

Lipase 2100 0-160 0-160

Amylase 400 28-100 0.48-1.7

AST 67 <35 <0.53

ALT 80 <45 <0.58

T Bili 2.1 0-2 0-34

Alk Phos 143 39-117 0.65-1.95

Sodium 141 136-145 136-145

BUN 28 6-20 2.1-7.1

Creat 1.0 0.6-1.3 53-115

Urine B-hCG Negative Negative Negative

Q2. Initial labs reveal the following:

A. 0.9% NaCl 2L bolus IV B. Abdominal free air series C. Acetaminophen PO D. Aspirin 325mg PO E. Ciprofloxacin and metronidazole PO F. Contact precautions G. CT scan abdomen with IV and PO contrast H. D5 0.45% NaCl IV at 100 cc/h I. Discontinue statin J. Fecal occult blood test K. Lipid profile L. Lorazepam IV M. Magnetic resonance cholangiopancreatography

(MRCP) N. Meperedine IV O. Morphine IV P. Pantoprazole bolus IV followed by continuous

drip Q. Piperacilin-tazobactam IV R. Stool C difficile toxin assay S. Ultrasound abdomen, right upper quadrant T. No action needed at this time.

What action(s) will you take at this time? Select up to 4.

A. 0.9% NaCl 2L bolus IV B. Abdominal free air series C. Acetaminophen PO D. Aspirin 325mg PO E. Ciprofloxacin and metronidazole PO F. Contact precautions G. CT scan abdomen with IV and PO contrast H. D5 0.45% NaCl IV at 100 cc/h I. Discontinue statin J. Fecal occult blood test K. Lipid profile L. Lorazepam IV M. Magnetic resonance cholangiopancreatography

(MRCP) N. Meperedine IV O. Morphine IV P. Pantoprazole bolus IV followed by continuous

drip Q. Piperacilin-tazobactam IV R. Stool C difficile toxin assay S. Ultrasound abdomen, right upper quadrant T. No action needed at this time.

What action(s) will you take at this time? Select up to 4.

KF2. Order an ultrasound to look for gallstones 1pt. U. Ultrasound abdomen, right upper quadrant

KF3. Initiate volume resuscitation and analgesia 0.5 pt A. 0.9% NaCl 2L bolus IV 0.5 pt O. Morphine IV

Exam Mean KFE% (StDev) Mean NBME% (StDev)

A 54.6 (9.6) 76.1 (14.2)

B 59.0 (8.7) 77.4 (8.1)

C 60.3 (8.4) 79.6 (10.6)

D 59.6 (9.5) 79.6 (7.7)

Form Correlation to NBME

A 0.24 **

B 0.42**

C 0.37**

D 0.47**

** p < 0.01

Total

Difficulty n (%)

Too easy 0 (0)

Just right 387 (75.1)

Too hard 127 (24.7)

Sufficient time

Yes 463 (89.9)

KFE for formative feedback

Yes 381 (74.0)

Change study habits if graded

Yes 352 (68.3)

Outcome: Retained complaints against practicing physicians

Comparison: Performance on Qualifying Exam (end of med school)

Exam Scores

Overall Clinical Skills

Communication

Data acquisition

Problem-Solving

Overall written exam

MCQ

CDM (KFE)

Tamblyn R et al. JAMA. 2007;298(9):993-1001.

Exam Scores Relative Rate 95% CI P-value

Overall Clinical Skills

1.19 1.00-1.42 .05

Communication 1.38 1.18-1.62 <.001

Data acquisition 0.98 0.83-1.16 .85

Problem-Solving 1.02 0.88-1.19 .76

Overall written exam

1.39 1.14-1.70 .001

MCQ 1.25 1.03-1.50 .02

CDM (KFE) 1.51 1.25-1.84 <.001

Tamblyn R et al. JAMA. 2007;298(9):993-1001.

Exam Scores Relative Rate 95% CI P-value

Overall Clinical Skills

1.19 1.00-1.42 .05

Communication 1.38 1.18-1.62 <.001

Data acquisition 0.98 0.83-1.16 .85

Problem-Solving 1.02 0.88-1.19 .76

Overall written exam

1.39 1.14-1.70 .001

MCQ 1.25 1.03-1.50 .02

CDM (KFE) 1.51 1.25-1.84 <.001

Tamblyn R et al. JAMA. 2007;298(9):993-1001.

Exam Scores

Clinical Skills Exam

Communication

Data acquisition

Clinical Management

Written

MCQ

CDM (KFE)

Tamblyn R et al. Arch Int Med. 2010;170(12): 1064-72.

Exam Scores OR 95% CI P-value

Clinical Skills Exam 0.78 0.69-0.89 <.001

Communication 0.89 0.79-1.02 .09

Data acquisition 0.88 0.78-1.00 .05

Clinical Management 0.87 0.78-0.96 .005

Written 0.77 0.66-0.89 .001

MCQ 0.82 0.71-0.94 .005

CDM (KFE) 0.74 0.63-087 <.001

Tamblyn R et al. Arch Int Med. 2010;170(12): 1064-72.

1. Identify clinical problem 2. Identify key features

• Consensus with dyad

• Consensus with table

3. Write case • Vignette, question, answer

options

• Review

Case and Questions

50%

Key Features

50%

Time

GERIATRIC COMPETENCY CLINICAL PROBLEM

Identify medications, including anticholinergic, psychoactive, anticoagulant, analgesic, hypoglycemic, and cardiovascular drugs that should be avoided or used with caution in older adults and explain the potential problems associated with each.

Insomnia Acute pain Depression Heart failure Diabetes mellitus

GERIATRIC COMPETENCY CLINICAL PROBLEM: FALL

In a patient who has fallen, construct a differential diagnosis and evaluation plan that addresses the multiple etiologies identified by history, physical examination and functional assessment.

GERIATRIC COMPETENCY CLINICAL PROBLEM: FALL

In a patient who has fallen, construct a differential diagnosis and evaluation plan that addresses the multiple etiologies identified by history, physical examination and functional assessment.

Setting

• Home

• Hospital

Other

• Without neurologic deficits

• With history and physical consistent with cervical stenosis

Common clinical scenarios • Think of your own experiences or your trainees’

• Inpatient/outpatient/other

Critical steps to identifying and/or resolving the problem

FACT RECALL CLINICAL REASONING

What are the four items on the CAM?

Recognize delirium in a patient

Delirium: Decisions • Order diagnostic workup (e.g. BMP)

• Treat underlying cause (e.g. hyponatremia)

GERIATRIC COMPETENCY KEY FEATURES (DECISIONS/STEPS)

Identify medications, including anticholinergic, psychoactive, anticoagulant, analgesic, hypoglycemic, and cardiovascular drugs that should be avoided or used with caution in older adults and explain the potential problems associated with each.

In an elderly patient with insomnia 1. Counsel sleep hygiene

2. Do not order diphenhydramine or benzodiazepines

Conditions

Task: Avoid Task

Vignette Answer stem Answer options

Authentic situation Enough info to resolve the problem Lay language

What is your leading diagnosis at this time? Which tests, if any, would you order at this

time? • If KF is to test high value care “select as many as

appropriate”

What steps will you take in your immediate assessment and management of this patient?

Identify correct options Identify poison options

• not in most cases

Create distractors • Common misconceptions

• Similar tasks

• Set limit, if any

• Allow up to one extra if there is a correct un-scored option

1 point per Key Feature • Within a key feature, if > 1 component, weigh each

equally

Poison answers= no points for that key feature