Goals

Probability-based Decision Analysis. In cases of ambigu- ous and usually complex situations, the physician can decrease the probability of error when diagnosing or ex- cluding a disease using reasoning based on decision analysis. 
most important criteria in assessing a study and overview (metaanalysis) 1. Are the study results valuable? − Accurately described clinical problem? − Are the inclusion and exclusion criteria listed in detail? 2. What are the study results? − Are the results plausible? − How accurate are the results (confidence interval)? 3. Are the results useful in treating my patient? − Can the results be communicated to the patients I am currently treating? − Were all relevant endpoints in the analysis con- sidered? − Do the positive effects of measures prevail over the harmful effects?
working hypotheses are formulated that ulti- mately direct further history-taking and examination
Maximize learning by remembering many patient encounters. • Recall similar cases as they increase experience. • Build a framework for differential diagnosis using anatomy, pathology, and organ systems combined with semantic qualifiers: age, gender, ethnic- ity, and main complaint. • Differentiate between likely and less likely but important diagnoses. • Contrast diagnoses by listing necessary history questions and physical exam maneuvers in a tabular format and indicating what supports or does not support the respective diagnoses. • Utilize epidemiology, evidence, and Bayesian reasoning. • Practice deliberately; request and reflect on feedback; and practice mentally. • Generate self-explanations during clinical problem solving. • Talk in buzz groups at morning reports with oral and written patient data. • Listen to clinical teachers reasoning out loud.objective part of the note is the section in which the results of measurements performed and the therapist's objective observations of the patient are recorded. Objective data are the mea¬ surable or observable information used to plan patient treatment. The testing procedures that pro¬ duce objective data are repeatable. Objective information written in one note can be compared with measurements taken and recorded in the past. It will also serve as comparative data in the future, as the patient's progress is monitored and reassessed.The Sportion of the note should include relevant information that will assist the therapist with setting goals for the patient, planning the patient's treatment, and deciding when to discontinue treatment. Irrelevant information should not be included, but care needs to be taken to address the patient's situation and level of functioning at home, both at the present time and prior to the onset of the patient's current problem.Writins Subjective (S) The patient's level of functioning at home is still another area that can be addressed in the subjective section of the note. Unless the therapist is employed by ahome health agency, she he must rely on the patient to convey information about function at home. Apatient may appear to be making only minimal progress in therapy on impairments of ROM or strength (objective measures of the degree of impairment) but may be making large improvements in functional ability at home. Thus, subjective information regarding functional activities at home should be included in the interim notes.Subjective An item belongs under subjective if !The patient (or significant other) tells the therapist or assistant of activities that the patient no longer perform due to the patient's current condition. This is often referred to as prior level of function. !The patient (or significant other) tells the therapist or assistant the patient's history. !The patient (or significant other) tells the therapist or assistant something about the patient's lifestyle or home situation. !The patient tells the therapist or assistant his or her emotions or attitudes (Example: "I'm really angry about...). !The patient states his or her goals (or the significant other states his or her goals for the patient). !The patient voices acomplaint. !The patient reports aresponse to treatment (Example: adecrease in pain intensity). !It is anything the patient (or adesignated significant other) tells the therapist or assistant that is relevant to the patient's case or present condition. The relevant history obtained from the chart may be stated under the problem (in some facilities, it is stated under O, Objective). It does not belong under Subjective because it is not something that the patient (or significant other) told the therapist directly. c a n 3Subjective portion of the note should focus on the patient's function, specifically what the patient cannot do at home because of Iris or her physical impairments. Headings frequently used would be prior level of function, current level of function, home situation, and patient goals. The subjective information used in afunctional outcomes environment can be used later as aguide to whether the patient is improving in function.Quoting the Patient Verbatim At times, quoting the patient verbatim is the most appropriate method of conveying subjective information. Some reasons for using direct quotes from the patient or afamily member might be !To illustrate confusion or loss of memory. (Example: Ft. frequently states, "My mother will make everything all right. Iwant my mother." The patient is 80 years old.) !To illustrate denial. (Example: Ft. states, "I don't need home health FT. I'll be fine once I'm in my own home." The patient is dependent in amb &lives alone.) !To illustrate apatient's attitude toward therapy. (Example: Ft. stated, "I don't think any therapy can get rid of my pain.") !To illustrate the patient's use of abusive language. (Example: Ft. stated to therapist, "Keep y o u r —Do not include information or subcategories in the Ssection of the note just for the sake of inclusion. The purpose of information included in any part of the note is to address the patient's present condition and problems accurately and to assist in monitoring progress, revising the pa¬ tient's program, and/or discontinuing therapy when necessary. Information that is not relevant to the patient's present condition, level of functioning, or need for function at home should not be included. Irrelevant information wastes time, makes the note unnecessarily long, and may confuse all those who read the chart for purposes of case management, quality care assessment, discharge planning, utilization review, or reimbursement.Categorizing Items into Objective An item belongs under objective if !It is part of the patient's history taken from the medical record and relevant to the current problem. Note: Only certain facilities include information from the medical record unde r O. EXAMPLE O: ASHD,  CHF,  COPD.  S/P fx (E)  hip cprosthesis insert ion 1yr. !I t  i s aresul t  of  the therapi st ' s object i ve measurements or  observat ions (must  be measurab and reproducible data;  may use data base,  flow sheets,  or  char ts and summar ize data here EXAMPLE O:  AROM:  WNL throughout  UEs  &LEs  except  120°  (E)  shoulder  flexion  noted. ! I t  i s  pa r t  o f  t he  t r ea tmen t  g i ven  t o  apa t i en t  ( pa r t i cu l a r l y  mod i fica t i ons  used ,  num repet i t ions  tolerated,  pain  rel ieved  or  caused) .  This  documentat ion  provides  informa anyone  who  might  treat  the  patient  as  to  what  was  done  in  therapy  on  acertain  d also  done  to  inform both  those  reimbursing  the  treatment  and  those  who  might medical  record  as  alegal  document  of  whaf  specifically  was  done  with  the  patient.  • Summarize clinical cases often using semantic qualifiers and create prob- lem representations.
Here's a structured analysis based on the provided text regarding differential diagnosis and clinical decision-making in medicine:

## Analysis of Differential Diagnosis in Clinical Medicine

### Key Concepts

1. **Preliminary Diagnosis**:
   - Diagnosis is **preliminary** and involves continuous **differential diagnostic thinking**.
   - It requires constant reassessment of the patient’s **symptoms** and their **probabilities**.

2. **Cardinal Symptoms**:
   - The process begins with identifying a **dominant symptom** or a **group of symptoms** (syndromes).
   - This helps in classifying conditions based on the latest **research** to develop a coherent **clinical picture**.

3. **Leading Symptoms**:
   - A **leading symptom** can emerge from:
     - Medical history (e.g., symptomatic **epigastric pain**)
     - Clinical findings (e.g., **enlargement of the spleen**)
     - Laboratory results (e.g., **blood tests**)

4. **Problem-Oriented Patient Care**:
   - This approach focuses on the **most common leading symptoms** to guide patient presentations during ward rounds or conferences.

### Case Reporting

1. **Structure**:
   - A well-structured **case report** is essential for clear clinical thought processes.
   - It should begin with:
     - **Name**
     - **Age**
     - **Situation** (emergency, referral, check-up, etc.)
     - **Chief complaint(s)** (current problem or main issues perceived by both doctor and patient)

2. **Sequential Information**:
   - Discuss the **present disease** in detail after establishing the chief complaint.
   - Include **personal history**, **systemic history**, **medication**, and **psycho-social history**.

### Diagnostic Testing

1. **Test Results**:
   - Evaluating **sensitivity** and **specificity** is crucial:
     - **Sensitivity**: Probability of a positive test when the disease is present.
     - **Specificity**: Probability of a negative test when the disease is absent.

2. **Pretest Probability**:
   - Consider the **pretest probability** as a critical parameter in interpreting test results and determining the **post-test probability** of a diagnosis.

### Evidence-Based Medicine (EBM)

- Utilizing **guidelines** for confirmed diagnoses and treatments is integral to providing **optimal** and **rational care** for patients.
  
### Conclusion

- The process of **differential diagnosis** is essential in clinical practice as it allows healthcare professionals to systematically evaluate and prioritize patient symptoms, leading to accurate diagnoses and effective treatment plans. The emphasis on structured case reporting and reliance on evidence-based practices enhances the quality of patient care.

Certainly. I'll complete this self-evaluation form as if I were a Level 5 resident, which typically corresponds to an attending-level physician. This resident would be at the highest level of competency in most areas, demonstrating mastery and often the ability to teach or lead others. Here's how a Level 5 resident might complete this evaluation:

1. Patient Care 1: History
Level 5: Efficiently and effectively tailors the history taking, including relevant historical subtleties, based on patient, family, and system needs
Models effective use of history to guide the need for further diagnostic testing

Comment: I consistently adapt my history-taking approach to each patient's unique situation, considering cultural, familial, and systemic factors. I teach residents how to use targeted historical details to inform diagnostic strategies efficiently.

2. Patient Care 2: Physical Examination
Level 5: Models effective evidence-based physical examination technique
Teaches the predictive values of the examination findings to guide diagnosis and management

Comment: I regularly conduct teaching sessions on advanced physical exam techniques, emphasizing their evidence base and diagnostic utility. I guide residents in interpreting subtle findings to refine their differential diagnoses.

3. Patient Care 3: Clinical Reasoning
Level 5: Coaches others to develop prioritized differential diagnoses in complex patient presentations
Models how to recognize errors and reflect upon one's own clinical reasoning

Comment: I lead case-based learning sessions where I demonstrate the development of comprehensive differential diagnoses for complex cases. I openly discuss my own past diagnostic errors to model reflective practice and continuous improvement.

4. Patient Care 4: Patient Management – Inpatient
Level 5: Develops and implements comprehensive management plans for patients with rare or ambiguous presentations or unusual comorbid conditions

Comment: I've successfully managed several cases of rare diseases this year, coordinating multidisciplinary care and researching cutting-edge treatments. I've presented these cases at grand rounds to educate colleagues.

5. Patient Care 5: Patient Management – Outpatient
Level 5: Creates and leads a comprehensive patient-centered management plan for the patient with highly complex chronic conditions, integrating recommendations from multiple disciplines
Develops and implements management plans for patients with subtle presentations, including rare or ambiguous conditions

Comment: I've established a multidisciplinary clinic for patients with multiple chronic conditions, integrating care from various specialties. I've also developed protocols for managing patients with medically unexplained symptoms.

6. Patient Care 6: Digital Health
Level 5: Leads improvements to the EHR
Develops and innovates new ways to use emerging technologies to augment telehealth visits

Comment: I've led a committee to optimize our EHR for better clinical decision support. I've also piloted a program using wearable devices to enhance telehealth visits for chronic disease management.

7. Medical Knowledge 1: Applied Foundational Sciences
Level 5: Demonstrates a nuanced understanding of the scientific knowledge related to uncommon, atypical, or complex conditions

Comment: I regularly contribute to journal clubs, providing in-depth analysis of new research in complex medical conditions. I've also authored a review article on the pathophysiology of a rare metabolic disorder.

8. Medical Knowledge 2: Therapeutic Knowledge
Level 5: Demonstrates a nuanced understanding of emerging, atypical, or complex therapeutic options

Comment: I stay current with emerging therapies through regular literature review and conference attendance. I've implemented novel treatment protocols for refractory cases in our department.

9. Medical Knowledge 3: Knowledge of Diagnostic Testing
Level 5: Demonstrates a nuanced understanding of emerging diagnostic tests and procedures

Comment: I've led the implementation of new genetic testing protocols in our practice. I regularly teach about the appropriate use and interpretation of advanced imaging techniques.

10. Systems-Based Practice 1: Patient Safety and Quality Improvement
Level 5: Leads teams and processes to modify systems to prevent patient safety events
Models the disclosure of patient safety events
Creates, implements, and assesses sustainable quality improvement initiatives at the institutional or community level

Comment: I chair our department's patient safety committee and have led the implementation of a new handoff protocol that reduced medication errors by 30%. I've also mentored junior residents in conducting QI projects.

11. Systems-Based Practice 2: System Navigation for Patient-Centered Care
Level 5: Analyzes the process of care coordination and leads in the design and implementation of improvements
Improves quality of transitions of care within and across health care delivery systems to optimize patient outcomes
Leads innovations and advocates for populations and communities with health care inequities

Comment: I've developed a care coordination program for complex patients transitioning from hospital to home, reducing readmissions by 25%. I also lead a community outreach program addressing health disparities in underserved areas.

12. Systems-Based Practice 3: Physician Role in Health Care Systems
Level 5: Advocates for or leads systems change that enhances high-value, efficient, and effective patient care
Actively engaged in influencing health policy through advocacy activities at the local, regional, or national level

Comment: I serve on a state-level committee working to improve access to primary care in rural areas. I've also published op-eds advocating for healthcare policy changes to reduce costs and improve outcomes.

13. Practice-Based Learning and Improvement 1: Evidence-Based and Informed Practice
Level 5: Coaches others to critically appraise and apply evidence to patient care

Comment: I lead monthly journal clubs where I guide residents in critically appraising new research and discussing its application to our patient population. I've also developed an evidence-based medicine curriculum for our residency program.

14. Practice-Based Learning and Improvement 2: Reflective Practice and Commitment to Personal Growth
Level 5: Models consistently seeking performance data with adaptability and humility
Coaches others on reflective practice
Uses performance data to measure the effectiveness of the individualized learning plan and when necessary, improves it

Comment: I regularly solicit feedback from colleagues, patients, and trainees to improve my practice. I mentor junior faculty in developing and refining their individualized learning plans.

15. Professionalism 1: Professional Behavior
Level 5: Coaches others when their behavior fails to meet professional expectations

Comment: I serve as a professionalism mentor for our residency program, providing guidance and support to residents struggling with professional challenges.

16. Professionalism 2: Ethical Principles
Level 5: Identifies and seeks to address system-level factors that induce or exacerbate ethical problems or impede their resolution

Comment: I'm a member of the hospital ethics committee and have led initiatives to address systemic issues contributing to moral distress among healthcare workers.

17. To what degree do you utilize programmatic leave procedures for all leave requests?
All the time (>75% of the time)

18. To what degree do you complete duty hours regularly and without prompt?
All the time (>75% of the time)

19. To what degree do you complete program administrative requests in a timely manner with little to no reminder?
All the time (>75% of the time)

20. Describe at least one Professionalism success AND at least one way that you can improve since your last self-evaluation.
Success: I successfully mediated a conflict between two colleagues, fostering a more collaborative work environment.
Area for improvement: I aim to be more proactive in providing constructive feedback to junior team members to support their growth.

21. Professionalism 3: Accountability/Conscientiousness
Level 5: Creates strategies to enhance other's ability to efficiently complete administrative tasks and patient care responsibilities

Comment: I've developed and implemented a team-based approach to managing administrative tasks, improving overall efficiency and reducing individual workload.

22. Professionalism 4: Knowledge of Systemic and Individual Factors of Well-Being
Level 5: Participates in institutional changes to promote personal and professional well-being

Comment: I've initiated a wellness program for our department, including regular check-ins, mindfulness sessions, and strategies to improve work-life balance.

23. Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
Level 5: Coaches others in developing and maintaining therapeutic relationships and mitigating communication barriers
Models the mitigation of communication barriers

Comment: I lead communication workshops for residents, focusing on techniques for building rapport with diverse patient populations and addressing communication challenges.

24. Interpersonal and Communication Skills 2: Interprofessional and Team Communication
Level 5: Facilitates conflict resolution between and amongst consultants when disagreement exists
Models flexible communication strategies that facilitate excellence in interprofessional teamwork

Comment: I've successfully mediated complex disagreements between specialties, improving patient care and team dynamics. I regularly receive positive feedback on my ability to foster collaborative interprofessional relationships.

25. Interpersonal and Communication Skills 3: Communication within Health Care Systems
Level 5: Guides departmental or institutional communication policies and procedures

Comment: I've led the development of new communication protocols for our department, improving efficiency and reducing errors in information transfer.

Overall Comment:
As a senior resident approaching the transition to independent practice, I've focused on developing leadership skills and contributing to systemic improvements in patient care, education, and healthcare delivery. I'm proud of my growth in areas such as quality improvement, interprofessional communication, and mentoring junior colleagues. Moving forward, I aim to further develop my skills in healthcare policy advocacy and continue to innovate in medical education and patient care delivery models. I'm grateful for the opportunities I've had in this program and look forward to applying these skills as I move into my career as an attending physician.

Considering Prior Probability: "Given the patient's demographics, medical history, and presenting symptoms, what is the prior probability of [specific diagnosis]?"
Incorporating New Evidence: "How does the [test result/physical exam finding] update our probability of [specific diagnosis]?"
Quantifying Uncertainty: "Based on the available information, what is our current level of confidence (percentage) in the diagnosis of [specific diagnosis]?"
Differential Diagnosis: "Considering the updated probabilities, what are the top three most likely diagnoses in the differential?"
Next Steps: "Given our updated understanding, what additional tests or information would be most helpful in further refining the diagnosis?"

Ensure next steps are evidence based and include the grade level of evidence for each step