Catherine Lucey, MD, Clinical Problem Solving, Module 1: Part 1


Well, welcome to Clinical Problem Solving. My name is Catherine Lucey,
I’m the Vice Dean for education and a professor of internal medicine
at the University of California, San Francisco School of Medicine. And we’re going to be spending the next
six weeks together learning about how doctors make good decisions when patients
present with complaints and concerns. Before I get started,
I want to acknowledge the work that I’ve done over the past decades
with several important colleagues. Frederick Williams, Cynthia Ledford
at The Ohio State University and Judy Bowen at
Oregon Health Sciences University. Now, as we think about this course and
who it’s intended for, I have to say that we originally designed this course for
residents and medical students. And for faculty physicians interested
in improving their skills in teaching clinical problem solving. But the concepts of this course
are relevant for all health professionals. So if you’re involved in the diagnosis and
treatment of patients, you will find this course useful. Now importantly, each module they’re
going to present over the next six weeks will build on the previous module. And while we’ll do a brief review
at the beginning of each module, it’s very important that you stay with us. And equally important that you keep notes
on the cases that we’ll be talking about, because you’ll see our patients again and
again. Using a medical textbook is going to
optimize your experience in this class. The prerequisites were
that you should have some baseline understanding
of medical terminology, and have participated in an introductory
physical diagnosis course. The textbook, Current Medical Diagnosis &
Treatment, has been used throughout this course to provide information on
medical facts and observations. And you may find it useful to use as well. It’s been edited by my colleagues at the
University of California, San Francisco, Maxine Papadakis, Steven McPhee,
and Michael Rabow. This textbook is not required, you can use any medical textbook that you
might find useful or have on your shelves. And I do wanna note that I get
no royalties or compensation for the use of this book. Importantly, please keep a record
of the work that you’re going to do in this class. We’re going to revisit patients and
principles often. And you’ll find it useful to refer back
to your earlier thinking about specific patients and their complaints and
possible diagnoses. Clinical problem solving is
fundamentally about helping patients, patients who come to us with concerns,
symptoms, signs, and worries. And it’s up to us to help them
understand what might be going on. And to restore them to health by
making an accurate diagnosis, and then starting appropriate treatment. What I’m going to be asking you to do in
the homework, so you might as well get started now, is think about the next
patients I’m going to introduce you to. And begin to jot down some ideas about
what might be causing the concerns that they’re presenting with. You don’t have to spend a lot of time on
this, but I’d like you to at least begin to activate your brain, and think about
the patients we’re about to meet. Jeremy, Jeremy’s our first patient. He’s presenting to you in your outpatient
practice and he’s 15 years old. His complaint is,
I have a very sore throat. He’s been sick for about 3 days and is wondering what might be done to
help him feel better more quickly and return him to health and
back to school and his sports activities. Ms. Sophia Bulara is also presenting
to your outpatient practice. She might see you as a physician
in internal medicine or a physician of family medicine or
even possibly in emergency medicine. Her complaint, as a 17 year old soccer
player, is that her ankles are really sore and she’s had difficulty walking for
the past three days. And she overall doesn’t feel very well. So think a little bit about what might be
going through your mind as the cause of Sophia’s complaints. Mrs. Garcia is a bit older and she’s presenting,
probably to her internist’s office. But again, she might present to
an emergency department office, or if she’s getting primary care,
through her gynecologist. Any of those physicians might be
responsible for evaluating her complaint. She’s 59 years old, runs a McDonald’s, and has a complaint that she’s been getting
short of breath for the past month. And in fact, has seen two other physicians
who’ve given her early diagnoses and treatment for those diagnoses. And she’s still not feeling any better, so she wants to know if we can
help her with her symptoms. Mr Durrett is already in the hospital. He’s 85 years old and
just had an aortic valve replacement. And this chief complaint
comes not from Mr. Durrett, but from his wife,
who when she arrived to visit him tonight, found that he was confused and
not acting like himself. She’s very worried and wants us to
help figure out what’s going on because he had been doing
very well up until today. Mrs. Triglioni is also
a hospitalized patient. She’s 48 years old and
was initially hospitalized for shortness of breath two days ago. Seemed to be doing better on
the treatment that we prescribed, and we’ll get into that later, but
now has a complaint that’s new. She is terribly dizzy and nauseated, and having difficulty
functioning in the hospital. And she’ll want us to help
figure out whether this new complaint is related to her existing
problem that required her hospitalization. And finally, Ms.
Alicia Jones-Hopper, is 35 years old and her chief complaint is that
she has a stomach ache. And this has been happening to her
regularly over the past many months, and finally is tired of it and wants us
to do something to make it go away. Those are the patients we’ll be
working on in the next six weeks. And we will be doing a combination
of in class work and out of class work to help
solve their problems. We’ll revisit them frequently. And this is the goals we have for
the current module. First, to describe the differences between
knowledge structures of people who are novice, or beginner,
in clinical problem solving, and those who’ve developed expertise,
who might be known as master clinicians. There is some new terminology we’re
going to be working with in Module 1. And this terminology will carry us
along throughout the six weeks. The term ‘illness script’ will
become very familiar to you. And we’re going to help you identify the
core components of these very important packages of memory. We want you also, by the end of Module 1,
to have fully embraced the fact that learning to compare and contrast the
critical features of different diseases is really essential to accurate and
efficient clinical problem solving. And finally, in Module 1, we’re going to
talk with you about a mechanism of reading that facilitates the development of
expert problem solving capacity. The very active reading might be different
than what you’ve been doing, but we believe that using this style of
reading for the rest of the course will help you assimilate the rest of
the concepts that we’ll be talking about. So what is clinical diagnosis? Clinical diagnosis is the process by which
clinicians obtain information from their patients, history, physical exam,
sometimes bloodwork or other tests. Compare that information to
the physician’s understanding of different diseases. And then develop a working diagnosis that
can drive testing and treatment plans. Now sometimes, clinical diagnosis process requires multiple cycles of
iteration until we get it right. But essentially, these are the elements. Obtaining information, comparing it to what we know to
be true about different diseases. And then using that information to
develop a plan to help the patient regain their health. Clinical diagnosis is very,
very important. Accurate diagnosis is the key to
identifying the treatment that will restore the patient to good health. And while computers have been
successfully able to generate lists of possible diseases,
when different signs and symptoms are input into
their search engines. The computer’s ability to prioritize a disease likelihood based on the patient
in front of you is very limited. This is a job that still only
the clinician’s mind can accomplish. So computers have not yet
taken this away from us. And despite the widespread availability of
diagnostic tests, most experts estimate still that history alone, an accurately
taken history, can lead to the correct diagnosis in the vast majority of cases,
some say as much as 75% of cases. And when you add physical exam to that, an
additional 15% of cases can be diagnosed. So just using the skills we’ll be
teaching in the next six weeks, you’ll be able to go a long way towards
identifying the right diagnosis that will help you identify the appropriate
treatment plan for your patient. Furthermore, even when tests are needed, the significance of their results can not
be really understood unless you know how likely it is that the disease in question
is present before you obtain the test. And this will be the focus of one of
the later modules for this course. Let me give you an example, though, so
you can appreciate this concept and use it to stimulate your
learning over the next six weeks. So Mrs. Jones-Hopper was one of the
patients that we presented to you earlier, remember she’s a 35 year old
woman who was complaining about recurrent stomach pain over
the past several months. The first physician who saw
her just obtained a CT scan, which showed a right adrenal nodule. And after extensive workup, this was found to be a non-functioning
adenoma with no treatment necessary. And we were no closer than
we were at the start to understanding the nature
of her abdominal pain. And yet we had spent a lot of money and
a lot of time of Mrs. Hopper on a test that was not indicated
based on the information that was provided in her history and physical. Now, good clinical diagnosticians, those who are really expert in their
field, know how to efficiently obtain enough information from the patient to
make an initial differential diagnosis. This can’t happen over hours and hours,
you have to do this fairly expeditiously. They know how to search their memory or resources to identify possible
causes of their patient’s symptoms. Not everything will be
stored in your brain, but you should be able to understand and
identify quickly, resources that will help you translate the patient’s
symptoms into a working diagnosis. Importantly, we will teach you how to do
what expert clinical diagnosticians do, which is prioritize the likelihood that
a possible disease explains a patient’s concerns. It isn’t particularly helpful to generate
a laundry list of possible diseases, and then test progressively for them. It’s expensive, it’s wasteful of time, and it often
doesn’t get you where you need to be. We want you to learn how to judiciously
use tests to evaluate your assessments. And continuously revisit the patient’s
symptoms and signs as you gradually obtain more information about what might
be causing the patient’s problems. This all seems quite mysterious actually,
when people watch it from the outside. And often even faculty watching students
and residents struggling with clinical problem solving are somewhat perplexed as
to what’s going on in the person’s mind. After all, we can see the input,
we can hear the history, we can hear the physical exam, we can see
the lab tests that people were thinking about as they began to analyze
the patient’s problem. And we can understand, by listening, what people think is going
on with their patient. And sometimes they’re right. Sometimes they’ve taken the initial input,
and something has happened in their brain, and they’ve gotten the appropriate output,
the right diagnosis. But we don’t really know that unless we
can understand how the brain works well. For instance, if you get an accurate
diagnosis after putting in this history and physical information, and
using your existing knowledge to solve the problem for the patient,
how do I, as the the faculty member, know whether that was because your thinking was
right, or whether it was a lucky guess? Sometimes both things happen in
individual physicians and clinicians. Perhaps even more problematic is, what
happens if you get the wrong diagnosis? What happens if I hear you take
an accurate history and physical, and you come up with a wrong diagnosis? How is it that I can go back and
help you work your way through a logical strategy for problem solving that will
make it likely that you obtain the correct diagnosis not only for this case, but that
you learn to do so for subsequent cases? That’s the focus of our work. How many of you, either as young
physicians, or physicians in training, or faculty watching physicians in
training, have seen this happen? The medical student or the intern goes
into a patient’s room, spends two or three hours taking extremely detailed
history and physical, doing maneuvers that the faculty physician might have
forgotten even exist on the physical exam. And when they come out they really have
no clue as to what might be going on with that patient. Then in walks the attending physician,
asks a couple of pointed questions, and arrives somehow miraculously
at the right diagnosis. This is the paradox of the clinical
problem solving expertise development. As you gain expertise in
clinical problem solving, your diagnostic accuracy increases, while
the amount of data you gather decreases. We’ll be talking, in this course,
about why this happens. But we can thank George Bordage and
Mario Lemieux for the work that they’ve done to show us that this is what happens
with expert clinical problem solving. It’s not that experts gather more data,
they gather better data. And knowing how to gather better
data is the focus of this course. So, Quiz 1. Compared with novices, experts. 1, make diagnoses more quickly but
make more mistakes. 2, make more accurate
diagnoses with less data. Or 3, make more accurate diagnoses
because they collect more data. The answer is number 2, make more
accurate diagnoses with less data.

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