Clinical Skills

• Clinical reasoning


  A complex cognitive activity by which clinicians collect, process and interpret patient information in order to develop a diagnosis, therapeutic decisions and prognosis
• Medical error


  A preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behaviour, infection, or other ailment
• The estimated incidence of medical error 'is unacceptably high' at 10–15%
• Reason for this lecture

  • To promote students performance and professional development in their OSCE exams related to history taking and clinical examination
  • To teach clinical reasoning early in the curriculum hoping to decrease incidence and consequences of medical errors in the future
• Clinical Reasoning (CR)


  A parallel process which guides the student to understand the framework by which the clinician solves the clinical problem (thinking like a doctor)
• Three dimensions to clinical reasoning

  • CR is a general skill like any other clinical skill
  • CR is also a function of memory or accumulated knowledge
  • CR utilises generalised mental representations such as: Semantic qualifiers, Problem representation, Illness scripts, Diagnostic schemas
• Managing cognitive load


  • Exemplars - a person or thing serving as a typical example or appropriate model
• Data Gathering


  1. Acquire Data: How to collect – standard format, Clarify and verify data

  2. Interpret and Organise: Create Problem List, Work out Semantic qualifiers, Chunk the data (Categorise it), Problem Statement/Representation
• Hypothesis Testing


  1. Make Differential Diagnosis: Pattern Recognition, If no Pattern Recognised (mnemonics): Anatomical Sieve (Organ system), Surgical Sieve (Pathophysiological)

  2. Test Differential Diagnosis: Illness scripts, Diagnostic schema, Diagnostic criteria & Threshold testing
• Dual Process Theory


  Explains how clinicians think when reasoning through a patient's case. Thinking is categorized in two systems: System 1 (Intuitive process) and System 2 (Analytical / Rational)
• System 1 (Intuitive process)

  • Mostly at the subconscious level/ automatic, Pattern recognition, More developed and used by experienced practitioners, Takes years to develop, Difficult to put into words, Low scientific rigor, Heuristics, Plenty of cognitive biases
• System 2 (Analytical / Rational)


  • Effort dependent, Hypothetico-deductive method, Requires knowledge, Easy to put into words, Repetitive use of System 2 leads to better understanding and development of System 1, Largely forms the basis of the medical education
• Heuristic


  A mental shortcut that allows experienced doctors to solve problems and make judgments quickly and correctly in 80% of cases in 5 minutes
• Three Main Sources of Our Cognitive Biases within System 1: Too much information, Too little information, Too much emphasis on speed
• Critical thinking


  The ability of thinkers to take charge of their own thinking - metacognition. This requires sound criteria and standards for analyzing and assessing one's own thinking and routine use of those criteria and standards to improve its quality
• Clinical Mnemonics for the Type 2 reasoning

  • Surgical sieve: MUNCHEBARS
  • Anatomical sieve: VITAMIN CDEF
• Illness script


  A mental summary of a disease in the physician's mind
• Diagnostic schema


  A systematic approach to a clinical problem by providing an organizing scaffold
• Diagnostic criteria


  A guide consisting of set of signs, symptoms, and tests developed for use in routine diagnostic and clinical care
• Threshold testing


  Testing the probability below which the diagnosis is so unlikely it is excluded without further testing
• Components of Illness Script: Epidemiology, Pathophysiology, Time course, Prominent Symptoms and Signs, Diagnostics, Treatment
• Benefits of Diagnostic Schema

  • Connecting diagnostic thinking to a logical framework
  • Avoiding false diagnoses
  • Triggering search for differentiating features
  • Helps teaching others how to reason
  • Creating Diagnostic Schema is beneficial to learning
• History Scenario Example: Demographics, Presenting complaint, History of Presenting complaint, Associated problems, Past Medical History
• History taking


  Helps teaching others how to reason
• Schema


  An efficient way to teach others how to approach a clinical problem ("think aloud")
• Creating Diagnostic Schema is beneficial to learning
• Through deliberate practice, learners adapt and individualize their schema — tying these frameworks to prior clinical knowledge and experience, which keeps them robust and accessible and allowing a schema to "work" best for them
• Demographics


  Mr Smith, 04/02/1986 (35 years), shop owner, married, two children, lives in flat in Johannesburg
• Presenting complaint


  I felt sick yesterday, felt hot and then I suddenly got very loose stools
• Severity


  I have to go around 7 times a day. I never measured temperature but I had chills
• Consistency


  It is watery. There isn't any mucus or blood in it
• What made it better

  I took some rehydration solution. I have also been vomiting a lot so I have not been able to keep anything down, so it made me only little better
• Associated problems


  I have been feeling a dizzy and faint. I have slight pain in my belly but it isn't too bad
• I cannot think of anything I ate that could be the cause
• One of my friends also has similar problems
• I have not had diarrhoea or constipation for many years now
• Past Medical History


  One day admission one week ago for chest infection. No other significant past medical and surgical history
• Drug History


  Antibiotics for recent chest infection
• Allergies


  Allergic to penicillin
• Family History


  Parents , 2 siblings and 2 children healthy