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 leaning 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 that I'm going to
present over the next six weeks will build
on the previous module and while we'll do
a brief review a 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 and
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
my, by my colleagues at the University of
California San Francisco. Maxine
Papadakis, Stephen 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 want to 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

diagnosis. 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 patents 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 is 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 three 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 also presenting to your
outpatient practice. She might see you as
a physician in internal medicine or a
physician in 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 is
presenting probably to her internist's
office, but aga in, 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 have 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
hosptalized 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've prescribed, and we'll get into that
later, but now has a complaint that's new.
She's terribly dizzy and nauseated, and
having difficulty functioning in the
hospital and she'll want us to help figure
out what, 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 patient, 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 c linical 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 are 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. It's a 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 blood work 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 di sease likelihood based on
the patient in front of you is very
limited. This is a job that still only
the, the clinician's mind can accomplish.
So computer's not yet taken this away from
us. And despite the widespread
availability of diagnostic tests most
experts estimate still that history alone,
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 percent of cases can be
diagnosed. So, just using the skills we'll
be teaching in the next six month, 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
cannot 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-hoppers was one of the patients that
we presented to you earlier. Remember,
she's a thirty-five-year-old woman who is
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 work up, this was
found to be a nonfunctioning 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 lot of time of Ms. 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 h ours 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 identify, identify, understand and
identify quickly resources that will help
you translate the patients 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, 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 in physical information and, and
using your existing knowledge to solve the
problem for the patient. How do I, as the
faculty member know, whether that was
because your thinkin g 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 taken 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
would make it likely that you obtain the
correct diagnosis not only for this case,
but that you learn to do 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 exists 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 Goerge
Bordash and Mario Lemieux for the work
that they have 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 having better data is the
focus of this course. So, quiz number one.
Compared with novices, experts, one, make
diagnoses more quickly, but make more
mistakes. Two, make more accurate
diagnoses with less data. Or three, make
more accurate diagnoses because they
collect more data.
The answer is number two, make more
accurate diagnoses with less data.