Using Illness Scripts to Teach Clinical Reasoning Skills to ... - STFM

256 April 2010 Family Medicineclinical reasoning in a systematic manner. The objectiveof our study was to determine if a brief workshopto teach students to refine their knowledge organizationthrough the use of illness scripts could improvestudents’ clinical reasoning skills for diagnosis.MethodsThe workshop started with a 20-minute lecture to allstudents. It introduced the key elements of the clinicaldiagnostic process. 6 This was followed by a 1-1/4 hoursmall-group tutorial on problem representation and developingan illness script and a final tutorial, also 1-1/4hours long, in the computing laboratory on developingand selecting an appropriate illness script. A manualfor teachers wishing to conduct a similar workshop isavailable from the authors by request.Problem Representation and Developingan Illness ScriptThe objective in the workshop was for students toacquire the skill of articulating the patient’s problemand to develop an illness script based on two clinicalscenario articles from the New England Journalof Medicine’s Clinical Problem-solving series. 7,8 Thepurpose was to help students develop a succinct andcoherent case presentation from the clinical problempresented in the journal article and to organize pertinentclinical data into a structured template (illness script) toformulate the basis of reaching a diagnosis. We chosethe articles based on the complexity of the scenario andthe perceived interest to students.A PowerPoint presentation of the clinical scenarioswas prepared by one faculty member before the workshop.Three other physicians from the Faculty of Medicineacted as tutors for the interactive sessions.The students were given the details of the clinicalpresentation, history, and examination results duringthe workshop. The tutor’s task was to guide the studentsto identify the important findings and to help themdevelop a presentation of the patients’ problems usingthe teaching strategies described by Bowen. 6 Studentswere expected to characterize the clinical problempresented in the two articles as “an elderly man with apersistent cough” 7 and “a middle-aged woman with anacute swollen and painful left leg.” 8The tutor then reasoned aloud to compare and contrasthis expert problem representation with those ofthe students. Students then developed an illness scriptby listing the enabling (predisposing conditions or riskfactors), fault (pathophysiological insult), and clinicalconsequences (key signs, symptoms, complaints) withfeedback from the tutor. A sample problem illnessscript for pertussis in “an elderly man with a persistentcough” 7 is shown in Appendix 1.Developing and Selecting an AppropriateIllness ScriptThe objective of this session was for students toacquire the skill of developing and selecting an appropriateillness script in formulating the most probablediagnosis for a given clinical problem. The purposewas to help students prioritize multiple diagnoses byidentifying discriminating features for each diagnosticconsideration. We developed a Web-based program thatwas comprised of a set of 20 clinical reasoning problems(CRPs) for teaching, combined with a scoring systemfor assessment. Our Web-based program was based onpreviously validated paper-based CRPs developed byGroves et al in conjunction with 22 family medicinephysicians at the University of Queensland. 9 Details ofthe scoring system for CRP are described elsewhere. 9The reliability of the paper-based CRP for medicalstudents ranged from 0.61 to 0.83. 9Prior to the implementation of the workshop, wetested the Web-based program on eight final-year studentswho were not involved in the study, to identifycomputing errors in the program and scoring system.The Web-based CRPs for post-workshop assessmenthad acceptable reliability (Cronbach’s alpha=0.80).For each CRP, students had to nominate the two mostlikely diagnoses, list the clinical features that supportedor opposed each diagnosis, and weigh each of the clinicalfeatures (slightly relevant, somewhat relevant, veryrelevant) from a series of drop-down menus. For thefirst CRP, two tutors interacted with students by askingthem to list all important findings from the case, createa problem representation based on those findings,generate and prioritize diagnostic considerations thatidentify discriminating features for each consideration,identify findings from the case to support the diagnosis,and lastly to identify and compare alternative diagnoses.6 Students were assisted if necessary at each stepto reach reasonable conclusions and, when appropriate,positive feedback for correct responses was provided.This was then supplemented by a tutor reasoning aloudto summarize the process and illustrate key componentssuch as the relevance of supporting clinical featuresassociated with the correct diagnoses.Students were encouraged to gradually work onfour other CRPs individually during the session, withindividual feedback from the tutors as they reasonedaloud. Thus, students were developing their own illnessscripts for each CRP attempted. At the end of eachcompleted CRP, the student was given an automatedscore by the program that gave immediate quantitativefeedback on their clinical reasoning skills. Toward theend of the session, the tutors reasoned aloud for theselected CRPs to illustrate the gap between actual anddesired expert performance. A sample CRP is shownin Appendix 2. The overall score for CRPs from theresponses shown in the tables was 28/37, as visceral