Expertiseontwikkeling bij medische studenten en professionals NVMO-conferentie November Klinisch redeneren. Gerritsma en Smal, 1982

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1 Expertiseontwikkeling bij medische studenten en professionals NVMO-conferentie November 7 Klinisch redeneren Henk Schmidt Instituut voor Psychologie Erasmus Universiteit Samen met: Els Boshuizen, Eugene Custers, Margje van de Wiel, Pie Hobus, Remy Rikers, Anique de Bruin, Peter Verkoeijen, Paul Wimmers, Silvia Mamede Gerritsma en Smal, 198 Hypothetico-deductie Echter: Barrows et al (1981): Beginnende studenten bezitten al hypothetico-deductieve redeneervaardigheden Norman et al (198): Expertise is inhoudsspecifiek Patel, Lesgold, Schmidt/Boshuizen (omstreeks 1985): Medische diagnostiek is een activiteit enkel gebaseerd op kennis!

2 Encapsulatie van biomedische kennis A. D. de Groot, 196 Geheugen en expertise bij schakers Geheugen voor midgame schaakposities % Correct a b c d e f g h Novice Class A player Master Grandmaster Level of Expertise

3 A 7-year old unemployed male A 7 year old unemployed male was admitted to the emergency room. He complained of shaking chills and fever of days duration. He took his own temperature and it was recorded at C on the morning of his admission. The fever and chills were accompanied by sweating and a feeling of prostation. He also complained of some shortness of breath when he tried to climb the two flights of stairs in his apartment. The patient volunteered that he had been bitten by a cat at a friend's house a week before admission. Functional inquiry revealed a transient loss of vision in his right eye which lasted approximately 5 ses. This he described the day before admission to the emergence ward. Physical examination revealed a toxic looking young man who was having a rigor. His temperature was 1 C. Pulse was 1 per minute. BP 11/. Mucous membranes were clear. Examination of his limbs showed puncture wounds in his left antecubital fossa. There were no other skin findings. Examination showed no jugular venous distention. Pulse was regular, equal and synchronous. The pulse was also noted to be collapsing. The apex beat was not displaced. Auscultation of his heart revealed a /6 early diastolic murmur in the aortic area. Funduscopy revealed a flame shaped hemorrhage in the left eye. There was no splenomegaly. Urinalysis showed numerous red cells. There were no red cell casts on microscopic urinalysis. Expertise growth from student to physician * 5 Diagnostic accuracy * Schmidt & Boshuizen, HS nd yr th yr 6th yr internists Level of expertise Free recall of endocarditis case One internist s recall 5 Propositions recalled 3 The patient is a young man with a high fever, who presents a septic syndrome. This suggests drugs use. He shows signs of thrombo-emboli, due to an affected heart valve. The tachycardia fits with an associated aorta vitium. 1 HS nd yr th yr 6th yr internists Levels of expertise

4 Explanation of endocarditis case by advanced student BP = 11/ Explanation of endocarditis case by internist BP = 11/ cat bite denial vasodilation endotoxine production drop in BP perhaps shock cat bite denial vasodilation endotoxine production drop in BP sepsis possible shock 7 year old male and unemployed drug abuse contaminated needles Invasion of bacteria Activation of antibodies Immune response fails. 7 year old male and unemployed drug abuse contaminated needles Invasion of bacteria Activation of antibodies Immune response fails. puncture wounds fever reaction toxic looking puncture wounds fever reaction toxic looking and cold shivers prostration and cold shivers prostration Temp /1 C sweating shortness of breath on exertion Temp /1 C sweating shortness of breath on exertion high pulse rate, regular,equal and synchronous high pulse rate, regular,equal and synchronous decreased resistance decreased resistance Studying the role of biomedical knowledge in diagnostic performance * Ontwikkeling van declaratieve netwerken in het geheugen Clinical knowledge.9 Diagnostic performance Biomedical knowledge -.15 Biomedical knowledge.9 Clinical knowledge.89 Diagnostic performance * De Bruin et al., 5

5 Encapsulatie van declaratieve netwerken in klinische concepten Expertise growth over the lifespan* Diagnostic Accuracy r = Years of Experience *Hobus et al., 1995 Ontwikkeling van ziektescripts Encapsulatie van declaratieve netwerken in klinische concepten

6 Ontwikkeling van ziektescripts A Patient The Green Card naam adres tel. b.c.g. var. rub. morb. tuss. di. pol. te. fam. Vinken Merelstraat galstenen hypertensie blgr. rh. anti-d. lu.r. tub.r. di. intol. hep. medicatie Lanoxin,5mgr.dd.Dichlotride 5 dd1 morb. oper. vroegere ziekten congenitaal cor vitium; parot 7 benigne mammatumor re Aortainsuff. Mitralisstenose pol. datum verschijnselen laboratorium diagnose therapie datum verschijnselen laboratorium diagnose therapie 1/3/8 neusverkouden xylometh.gtt. 3/7/8 cardioloog: opname decomp.cordis 13/11/83 griepspuit 5/3/85 cardioloog: patient niet meer op afspraak gezien vrn. vrn.gezh. fin. vorige huisarts Z.Z.L. 1/1/86 griepspuit, zag zin van cardiolog. controle niet meer in. O/RR 13/ Diast.S. pulm. basaal crepiteren iter Dichl.Lanox. geb beroep nr. rub. scarl. tub. tuss. varic. A Complaint Doctor, I had such a high fever last night that I was in my bed shaking violently!

7 Role of context in expertise * Role of context in expertise * Number of correct hypotheses 1 Number of correct hypotheses 'Novice' Physicians 'Novice' Physicians General Practitioners General Practitioners cases with contextual information cases with contextual information cases without contextual information * Hobus et al, 1995 * Hobus et al, 1995 Transitory stages in expertise development Automatization in experts: Good or bad? * Acquisition of sal pathophysiological (biomedical) networks Encapsulation into higher level (clinical) concepts Simple cases 1. Aortic dissection. Acute endocarditis 3. Lung cancer. Sarcoidosis 5. Inflammatory bowel disease Complex cases 1. Addison s disease and tuberculosis. Acute salpingitis with perihepatitis 3. Pneumonia with sepsis. Appendicitis with perforation 5. Necrotizing fasciitis Development of illness scripts 6. Stomach carcinoma 7. Cushing s disease 6. Acute myocardial infarction and subarachnoid haemorrhage 7. Claudicatio due to occlusive arterial disease 8. Systemic lupus erythematosus 8. Non-Hodgkin s lymphoma with haemolytic anemia * Mamede & Schmidt, 7

8 Automatization in experts: Good or bad? * Automatization in experts: Good or bad? * * Mamede & Schmidt, 7 * Mamede & Schmidt, 7 Implications for teaching and learning in medicine Teach basic science only to the extent that it is relevant to medical practice Integrate biomedical and clinical science as much as possible Allow students to work with patient problems early Allow them to see many, and many different, patients Allow them to elaborate on patients together with peers How many patients do students see? (Wimmers et al., 6) 1-week internal medicine clerkship Use of logbooks Students saw 3 patients on average 16 different diseases were seen on average

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