in their brains, so that they can access it when they need to help patients in the clinical environment. First let's remember how, the young clinicians learn about disease and understand disease. and this may vary depending on how different health profession schools present the information, but in general, there's four general categories of information that people learn to master in order to diagnose appropriately. First, how the body is supposed to function normally, how things normally work. Generally, that's our first introduction to clinical problem solving. Then, we need to understand how things go awry, and when they go awry, what are the syndromes that result? And a syndrome is nothing more than a collection of clinical signs and symptoms. Finally we need to understand what type of diseases cause those syndromes. These are precise, classified phenotypes of diseases that lead us to the appropriate treatment and prognosis for a patient. When novices or beginner clinical problem solvers learn all that information, how things function normally, how things go awry, what kind of sine, [sinus[ symptoms or syndromes result from that and what diseases might be causing that, how do they store that information? Well typically, it is stored in a sequential manner in isolated folders, maybe a folder on vasculitis and then one on aids and one on myocarditis and one on TTP or thrombotic thrombocytopenic purpura. And then they stack these folders in somewhat of a random order. they're not necessarily nicely organized in the file cabinets you might hope to have in your home or, or work office. Now the filing system organization that is chosen by a beginner really depends to a large extent on how the material has been presented or taught in the classroom, and some schools do this by mechanisms. You might have a course on immunology, or neoplasia, or metabolism and metabolic disorders. Other schools arrange their curriculum in organs or systems, and so the file folders would be organized in cardiovascular disease, respiratory disease, GI disease. And some might actually choose to be more conventional and present information in traditional scientific disciplines like pathophysiology, pharmacology, and biochemistry. And in that case, your file
organization or schema will look a lot
like the courses in which you were taught. Now the problem with classifying them, either by mechanisms or by disciplines or by organ systems, is that patients don't generally come in with complaints in categories. And so, it's hard to access information when you store it in a way that's different than the problem is presented in your clinical office. Patients come in and they say, why do I have this funny rash, rather than is it possible that I have leukocytoclastic vasculitis? Although thanks to Google and many other search engines, some patients will come in and ask do I have leucoytoclastic vasculitis? But the vast majority are going to want you to look through your brain, through all of those file folders you've stored, and come up with an answer to why do I have this funny rash. Now what's most interesting about clinical problem solving to me is in fact the work done by Georges Bordage and other cognitive psychologists that point out that as people desire or aspire to become sophisticated problem solvers, it isn't just about adding more facts and information about multiple new diseases to your brain. It's about fundamentally changing the way in which those facts are stored and used. And the knowledge organizational schema that you need to aim for as you're developing expert clinical problem solving skills, is one that allows you to access the information easily in the clinical environment. So remember that picture of the stack of sort of random file folders that represents the storage strategy for novices. And compare it to what experts use as a knowledge storage strategy represented schematically on the next slide. So experts really re organize their knowledge throughout their career. Away from isolated independent stacked file folders, sitting in the corner of their brain, or even a little bit more organized in a filing cabinet, to a much more relational way of understanding diseases represented here by the circles. Syndromes represented by the triangles, and isolated signs and symptoms, represented by this polygon here. It is essentially a new neural network that can be entered at any level. You can enter it if you want to learn about a disease. You can enter it if you want to analyze a syndrome, or you can enter it because a patient has described a particular symptom. But what's important you
understand here, is that every disease
syndrome, signs, and symptoms is connected in your brain to multiple other sites of interest, and we'll show how those interrelate over the next several weeks. So let's look more carefully at how a expert clinician in the clinical environment would take advantage of this more coordinated and connected neural network of facts and information about diseases, and how they relate to signs and symptoms. So say a patient comes in and complains about symptom number 2. Well, understanding the way in which that expert's brain is organized, they will then seek to see whether that patient also has symptom number 1. And if so realize that, that constellation of symptoms can be described by this syndrome and therefore might be caused by one of these 2 diseases, but not by this disease over here. Alternatively, if the patient was symptom 2 says no to do I have symptom 1 and instead has these other symptoms, an entirely different trajectory of diagnosis is chosen, a different syndrome has been described, and it could be one of these three diseases but not this disease. That's how this schematically looks, if you were to pour into, or peak into the brain of an expert. Let's take a little closer look at how these diseases might relate to each other. Now what's true about clinical problem solving is that many dise ases can cause the same syndrome. And a syndrome again, is just a constellation of signs and symptoms. So let's look at the syndrome of pharyngytis. , Remember, Mr. Leader, our first patient, Jeremy, has a sore throat. We'd call that pharyngitis. We know from our reading that pharyngitis can be caused by group A beta-hemolytic strep. That's called streptococcal pharyngitis. It can be caused by infectious mono, or the Epstein-Barr virus. And it can be caused by the acute retro-viral infectious syndrome or HIV. All of these things have, diseases have one thing in common in this particular clinical setting, and that's they all can cause sore throat. So how do we know, in a given patient, whether it's more likely that they have mono, strep throat or acute HIV? We look for some critically important features. We look for differentiating features. That is, features in this symptom complex, or syndrome complex of three possible causes of sore throat, are only present in two out of three similar
diseases. So we look for something like,
for instance an on the tonsils that occur in infectious mono in streptococcal pharyngitis. If that's present, we know that it's more than likely it's one of these two diseases rather than an acute retro-viral infection. Every now and then we'll find a feature that in this set of diseases only occurs in one condition, and we call that a key feature. So here's some terminology we're going to be referring back to throughout the, course. Differentiating feature, which is a sign or a symptom in a given constellation of diseases that only incurs in two out of those three diseases and allows you to exclude the possibility that the third disease is present. And the other is key features, which is a feature that is present in this particularly grouping of diseases and only one out of these three conditions. So if a person comes in with strep throat and has a particular symptom or sign or lab test, we know that in fact what they have is streptococcal pharyngitis. And we'l l elaborate more on this a little bit later. Quiz number two. When thinking about clinical problem solving, all of the following are true except number 1, knowledge organization is as important as knowledge acquisition. Number 2, experts organize knowledge the way they were trained to in medical school. And number 3, in general many diseases can present with the same syndrome, a collection of signs and symptoms. And the answer is, number two is incorrect. Experts organize knowledge the way they were trained to in medical school is incorrect. Experts reorganize knowledge throughout their career into a more integrated, and interconnected neural network of facts and information about patients and diseases. And when we come back, we'll talk about how they begin to indentify what facts and information is important to store in that neural network.
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