Core Faculty Development
November 18,2013
Introduction to Clinical Reasoning
Role of Chart Stimulated Recall (CSR)
Demonstration and group activity exploring
strategies and skills for CSR implementation
The cornerstone of clinical competence
the reasoning underlying the steps taken
and decisions made by the trainee in relation
to their role in the work-up and management
of the patient.
Knowledge Patient’s story
Data Acquisition
Accurate problem
Context representation
Generation of hypothesis
Experience Search for and selection of
illness script
Diagnosis
Correct Correct
diagnosis reasoning
Internal process
Frequently inferred, not directly measured
Need to externalize process to measure it
New world of milestones requires us to
measure
Chart stimulated recall (CSR)
Uses a medical chart to stimulate the resident’s
recall of a particular case and its management
Targets clinical reasoning / judgment
Uses the note as a reference point for structured
clinical questioning
Ongoing dialogue between learner and teacher
Developed in 1970s for EM physician training
Chart review followed by discussion
Examiner probes clinical reasoning
Range of settings and level of trainee
Valuable for addressing ACGME competencies
Patient care - Medical knowledge
Systems-based practice -Practice-based learning
Enables faculty to assess a trainee’s rationale
Diagnostic and treatment decisions
Other options considered, but disregarded
Reasons why the other options were ruled out.
Allows faculty to investigate other factors
that influenced clinical decision-making
(e.g. environmental factors, family dynamics, etc.)
Milestones / EPA’s
Supervision / Documentation Review
Direct observation of the Learning Process
Enhances educational mission of rotation
that have generally been service-based (e.g.
Night Float)
Face-to-face meeting
Faculty does initial review of chart
Resident “presents” the note
Relevant open-ended questions guide the interaction
Probing questions to investigate knowledge,
reasoning, and judgment
CSR Worksheet Completion
Post encounter presentation – inpatient or
ambulatory
End of rotation discussion
Baseline / annual review /promotion
Remediation
After direct observation
Allow resident to present parts of the case
and probe after each major section (e.g. HPI,
PE, A+P) and then review the note in total.
▪ Good for the struggling or novice learner
Allow the resident to complete the full
presentation and then focus on the A+P and
note as a whole
▪ Better for the advanced learner.
Timely feedback in authentic practice
Explore reasoning in diagnostic and
treatment decisions
Probe for advanced level understanding
Appropriate for formative and summative
assessment
Gaps in knowledge and reasoning ability
Premature diagnostic closure
Inappropriate management choices
Poor organization
Lack of patient-centered care
Incomplete documentation
Practical Professor, Chart Stimulated Recall,
http://www.praxcticalprof.ab.ca/teaching_nuts_bolts_chart-stimulated_racall.html
Formative:
An excellent source of feedback to trainees on
performance on a case
Feedback that is ‘in context’, specific to a case, based on
what the trainee did in a real practice situation – the very
best way for new learning to be understood and
remembered
Summative:
Requires deliberate sampling over several cases (cases
selected by age, gender, problem, clinical task, …) – a
‘blueprint’
Sample size – likely 8-12 cases over a period of time
Start with relevant, open-ended questions
Assess understanding of H+P / diagnostics
Assess clinical reasoning and synthesis (A+P)
Assess for completeness
Check for internal consistency and discordance
Review the CSR Worksheet
Complete CSR worksheet to see if all
elements present
Evaluate the quality of job done by use of a
CSR evaluation
CSR exercise in a woman with back pain
“The Novice Learner”
CC: Back pain
HPI:
44 year-old woman with HTN, diet-controlled diabetes,
remote breast cancer, and asthma who was in her usual
state of health until 2 days ago. While getting up from the
couch, she experienced significant pain in mid/lower back.
Pain was severe enough to cause her to sit right back down
Pain mostly in mid-line with some radiation across to left flank.
The pain was mildly improved with 600 mg of ibuprofen
Able to ambulate, but difficult because of the pain.
Standing for long periods of time worsens the pain.
Lying down may improve pain, but can only lie on her side to
sleep
Pain slightly improved over past 2 days, but still rated as a 7/10
No f/c/n/v/d
No CP/SOB/ orthopnea
20 lbs of weight loss over the past 3 months,
but she has been “watching her diet.”
No change in bowel or bladder habits, except
a bit more constipation than normal
“All other systems were reviewed and were
negative”
PMH:
HTN (well-controlled)
DM (diet-controlled)
Hypercholesterolemia
Asthma since childhood (4 admissions / year)
Breast cancer 1997- s/p lumpectomy and XRT
Mild depression
PSH:
s/p T+A as child, lumpectomy (1997)
FHx:
No early CAD or cancers
SHx:
Negative x 3
Allergies : PCN (rash)
Meds:
Red yeast rice
Lisinopril 20 mg qd
Levothyroxine 88 mcg qd
Fluticasone/ Salmeterol Disk 250/50 BID
MVI
ASA 81 qd
Ibuprofen prn
Is there a clear CC?
Is the HPI consistent with the CC?
Is the HPI clearly communicated?
Is there an appropriate/thorough ROS?
Are there any PMH/PSH components that are
of special interest to you?
What sort of things should you focus on in
your physical exam?
T: 97.9 BP: 148/86 P:96 RR: 20 SaO2: 99%
Gen : Patient sitting somewhat uncomfortably (2/2 pain)
HEENT: Atraumatic, PERRLA, EOMI, OP benign
Neck: Supple, no LAN
CV: Mildly tachy, +S1, +S2, 1/6 SEM at RUSB
Resp: Decreased breath sounds at left base. o/w CTA
Abd: Soft, NT,ND, BS+
Ext: No C/C/E
Back: Midline tenderness noted lower thoracic/upper lumbar
spine. Mild paraspinal tenderness bilaterally
Neuro: CN 2-12 intact, BUE with 5/5 strength, DTRs 2 + and
symmetric. LE strength 4/5 bilaterally (? secondary to pain), 3+
DTRs bilateral patellar tendon, ankles 2+ and symmetric.
Rectal: not done
Is the physical complete and appropriate?
Are all pertinent history elements thoroughly
evaluated by the physical exam?
Are there any elements of the physical exam
you would have liked to have added?
What are the “pertinent positives” and
“negatives?”
What diagnostics are appropriate and why?
10.6 138 108 22
12.2 569 156
4.2 22 1.1
MCV 92
AST 45 Alk Phos 324
ALT 66 T. Bili 1.2
Albumin 2.8
Calcium 8.9
EKG – Sinus tachy. Nonspecific ST/TW changes
CXR (PA/lat) –Mild to moderate-sized left pleural effusion with mild compressive
atelectasis . Lungs are clear otherwise. Incidental note made of a compression
fracture at L2 with moderate wedge defect. Could be osteoporotic in nature, but
cannot rule out pathologic fracture.
Clinical correlation suggested.
1. Back pain – X-ray revealed compression fracture at T12. Will attempt to get better pain control
with IV morphine. We will consult Orthopedics to assess need for brace. Consider MRI to better
evaluate for cord compression and need for surgical intervention. PT/OT. Given the patient’s
age, we will need to evaluate for causes of premature osteoporosis. She does have frequent
asthma flares which likely are treated with prednisone. Will check TSH, PTH, celiac antibodies.
2. Elevated LFT’s. Check Hep panel and RUQ U/S.
3. Anemia – Check iron studies, B12, folate, retic count
4. Thrombocytosis – likely reactive. Will follow.
5. Diabetes - Diabetic diet and QID fingersticks. If sugars are elevated consider sliding scale
insulin. We will check a hemoglobin A1C to get a sense of outpatient control. If suboptimal, will
consider adding metformin.
6. HTN – Continue lisinopril for now. It may be elevated by pain. If BP continues to be elevated
despite adequate pain control, consider adding HCTZ.
7. GI Prophylaxis – omeprazole 40 qd
8. DVT Prophylaxis – As the patient not very ambulatory, we will use SQ low molecular-weight
heparin
Based on the H+P, is the patient sick or not sick?
What is the leading diagnosis of the patient’s
symptoms?
Does the information in the H+P / Diagnostics
support the diagnosis?
What else is on the differential diagnosis?
What features in this case led you to believe that
the leading diagnosis is correct?
How might you definitively make your
diagnosis?
ANY OTHER QUESTIONS???
Where is your plan for the pleural effusion?
What are some causes of pleural effusions?
What are causes of anemia in a patient like this?
Does this patient need a PPI for GI prophylaxis?
Does anyone need GI prophylaxis?
Does the document allow the cross-cover team
to respond to unexpected changes in the
patient’s clinical status?
Time for the Form
See CSR worksheet
Break up into groups of three
Learner (intern), examiner, and observer
Use H&P in your packet
CSR Worksheets ( questions , evaluation
sheet)
The Advanced Learner
Review the note in its entirety (not in sections)
Use CSR question sheet
Complete evaluation
Was it easy to identify “teaching moments?”
Were you able to develop an accurate
assessment of knowledge, clinical reasoning,
and application?
Was the note clear and could it function as a
“stand-alone document?”
Chart stimulated recall in action
http://www.practicaldoc.ca/teaching/practica
l-prof/teaching-nuts-bolts/chart-stimulated-
recall/
What is the format for the dialogue?
What type of questions are asked?
How does the attending probe reasoning?
What additional questions would you ask?
Inexpensive and easy to teach
Uses patients/clinical scenarios that are relevant, in “semi-
real time” and familiar to the trainee
Allows faculty to assess clinical reasoning / judgment,
knowledge, and documentation
Great for identifying errors from…
Knowledge deficits
Recognition / identification of important historical/PE clues
Premature closure
Inappropriate synthesis
Inappropriate management choices
Adaptable to learners at multiple levels
(Novice/Advanced)
CSR Rating Form
Doctor Assessor
(please print name) (please print name)
Doctor’s level of appointment (e.g., PGY1) Setting ____________________ Problem complexity ( check one) ____ Low ___ Moderate ___ High
Patient Problem/Dx(s) Age Gender
Discipline ________________________________
Following your discussion of this case with the doctor, circle the rating which matches your assessment of their performance.
1. Clinical record keeping
123 |456 |789
Unsatisfactory Satisfactory Superior
2. Clinical Assessment (including diagnostic skills)
123 |456 |789
Unsatisfactory Satisfactory Superior
3. Medical treatment
123 |456 |789
Unsatisfactory Satisfactory Superior
4. Investigations and Treatment
123 |456 |789
Unsatisfactory Satisfactory Superior
5. \ollow-up and Management Plan
123 |456 |789
Unsatisfactory Satisfactory Superior
6. Clinical Reasoning
123 |456 |789
Unsatisfactory Satisfactory Superior
7. Overall Clinical Care
123 |456 |789
Unsatisfactory Satisfactory Superior
Select References:
Bowen, J. Educational strategies to promote clinical diagnostic reasoning. NEJM .
2006;355(21):2217-2225.
Brown N.,Doshi M. Assessing professional and clinical competence: the way forward. Advances
in Psychiatric Treatment. 2006(12):81-91.
Epstein R. Assessment in medical education. NEJM. 2007;356(4):387-396.
Jennett P. & Affleck L. Chart audit and chart stimulated recall as methods of assessment in
continuing professional health education. Journal of CE in Health Prof. 1998;18:163-171.
Kogan,J. et al. Tools for direct observation and assessment of clinical skills in medical trainees.
JAMA. 2009;302(12):1316-1326.
Schipper S. ,Ross, S. Structured teaching and assessment: A new chart-stimulated recall
worksheet for family medicine residents. Canadian Family Physician. 2010,56:958-59.
Wass, V. et al. Assessment of clinical competence. Lancet. 2001;357:945-49.
Select Resources
Practical Professor, CSR Overview and Video Demonstration
http://www.practicalprof.ab.ca/teaching_nuts_bolts/chart_stimulated_recall.html
Learning Strategies Chart Stimulated Recall
http://www.academicsupportplan.com/(S(gvnf5nalc1fgiz55eszhf5mc))/LearningStrategies.
aspx?panel=chartstimulated
