So let's get started learning how experts

organize their knowledge and information

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.