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Class time can then be effectively used to teach the complex process of medical decision making in patients with a broad range of symptoms, the typical setting of primary care, and to explore ways how to deal with the connected uncertainty. We redesigned a seminar on differential diagnosis in primary care for undergraduate students, using an inverted classroom approach.

In this study we wished to address the following questions:. What will the gain in skills and knowledge of students learning with the inverted classroom approach be? All participants of this elective seminar were in their fourth or fifth year of undergraduate medical studies. The different modules consist of interdisciplinary clinical pictures derived from the everyday routine of primary care.

Differential Diagnosis in Primary Care

A special focus was put on the diagnostic accuracy of symptoms and signs in regard to the different underlying disease aetiologies of a given clinical picture. The whole seminar takes place at an interactive skills lab attached to the Marburg University Hospital and utilizes trained simulation patients and different models. Further details of seminar content and underlying didactic considerations have been published elsewhere [ 21 ]. One year ago, we redesigned the whole seminar, using the inverted classroom approach [ 22 , 23 ]. At the faculty of medicine, our seminar is currently the only taught medical course using the inverted classroom design.

To our knowledge, this method is so far also not used by other primary care departments in Germany and in general not yet widely established in medical education at German Universities. Each seminar session is structured as follows:. Preparation: Several video and audio lectures giving introductory information and key knowledge content are available on the web-based learning platform.

Face-to-face teaching, which takes place in the interactive skills lab: several didactic approaches, such as simulation patients, training models, interactive small group work, and quiz exercises are used. Follow-up: Additional video and audio lectures present more detailed information in regard to the single leading symptom and its underlying etiologies. Supplementary facultative reading material e. Student satisfaction research question 1 was measured using information from different sources.

The first source was a standardized questionnaire that is used by the University of Marburg to evaluate seminars. In addition, after the 8th out of 14 course sessions, an evaluation consisting of a focus group discussion and a short questionnaire that was handed out after the focus group were conducted. We concentrated on the learning experience of the course participants, with a special focus on how the inverted classroom approach is perceived. For the quantitative evaluation of gain in skills and knowledge research question 2 we designed a questionnaire consisting of extended matching items 13 items , and key-feature tests 20 items.

Both examination formats can measure the process of clinical reasoning, and help to assess clinical decision making skills [ 24 , 25 ]. Together, both question formats covered all major seminar content. Questions were pre-tested on another group of students with comparable pre-existing knowledge. After the pre-test we replaced two key feature cases that were too easy and one extended matching question that was too difficult and in addition modified one key feature question that was misleading. During the seminar, students were asked to complete the pre-test at the beginning of the first session, and the post-test after the last session before starting to learn for the OSCE that was conducted one week later.

Tests were completed by students using an unique identifier that allowed the anonymous matching of pre- and post-tests at an individual student level. Additional file 1 shows example questions of the questionnaire. For the 4 variables of the standardized questionnaire for student satisfaction means and standard deviations were calculated and plotted.

Results average in percentage of maximal test score that could be gained of the pre- and post-test were compared for statistically significant differences using the Wilcoxon matched-pairs signed-ranks test. Error probability with a p-value less than 0. The focus group discussion was taped and transcribed verbatim. For data analysis we utilised a deductive approach based on the questions of the focus group guideline and of the short written questionnaire.

Analysis was performed by SB and results discussed among all authors. Responses from the focus groups and the free text answers from the evaluation questionnaires were grouped under different themes. The entire here presented data are part of the routine evaluation of courses at our faculty. Ethical approval was therefore not required. Altogether, 17 students applied and were all enrolled in the seminar. One student did not participate in the pre-test.

All 17 students took part in the focus group and the final evaluation. The inverted classroom concept of the seminar reached the highest possible marks. Interaction with students and the relevance of the course contents were rated accordingly. The quantity of material offered, and the complexity of course content were rated as completely adequate. Red bars reflect mean values and horizontal bars reflect standard deviations. Answers from the focus group discussion and the evaluation questionnaires can be grouped under the following themes:. All students appreciated the symptom-oriented approach, which was seen to reflect the reality of daily practice.

This is what usually lacks in other seminars or lectures … it is difficult to remember all the differential diagnoses, because you have to screen all diseases that you know in order to see whether these contain the symptom… here in this seminar it is the other way around. Most students mentioned that the seminar helped to understand the importance of epidemiological knowledge for the diagnostic process and the integration of this knowledge into the process of clinical decision making. The blended learning design of the seminar using an inverted classroom approach was appreciated by all students, as it gave more time during the seminar to concentrate on interactive and practice based learning.

The immediate application with the help of simulation patients is very practical. Some students criticized the fact that key information of the preparation videos was repeated during the face-to-face sessions. Several students mentioned the positive impact of teamwork during the seminar — a key competence that was also considered as important for later professional life. I think that this is also important for being a doctor later, to learn this capacity for teamwork. For some students the seminar was also a trigger for meta-learning, as they reflected their own learning experience.

Then I am most creative and it the knowledge remains in the long-term memory. Upper part: Overall results of the written pre- and post-test including confidence intervals. Percentages of the total number of possible points are presented indicating absolute gain in skills and knowledge. Lower part: Results of the written pre- black color and post-test grey color stratified by test format. Gain in skills and knowledge of each individual course participant. We aimed to give a first account of the effects of a blended learning program in primary care with this study.

To our best knowledge the above presented seminar is the first to teach differential diagnosis in primary care for undergraduate students using an inverted classroom approach. Our evaluation showed both a high satisfaction rate and a significant gain in skills and knowledge. The high approval of our blended learning approach is consistent with the available literature.

Our finding of high student satisfaction with this approach especially, is supported by the — presently sparse- literature in the field of medical education. While we could not identify evaluations of other primary care programs that use the inverted classroom model, there have been programs in teaching palliative care skills [ 19 ], cardiovascular, respiratory and renal physiology [ 20 ], renal pharmacotherapy [ 17 ] and perfusion skills [ 18 ]. All of the above mentioned programs used the inverted classroom approach and were positively evaluated, which supports our own findings.

An additional finding in our focus group discussion was that the new learning experience during the seminar also triggered part of the participants to critically reflect on their own learning. He encourages a deep approach to learning which includes the promotion of guided self-questioning, using other students as a resource or to derive own heuristics to suit a given task [ 30 ]. All these mentioned elements can be found in our course and it is interesting to note that an innovative and unusual teaching approach can trigger this kind of critical self-reflection, which we consider an important prerequisite for later professional life.

While a broad acceptance of participating students is surely a precondition for establishing a successful blended learning program [ 31 ], there should also be a positive impact on clinical skills. In one study students rated e-learning just as highly as alternative traditional methods of clinical skills teaching [ 9 ]. However, the effectiveness of blended learning is often difficult to quantify [ 5 , 6 ]. In addition, the results of a systematic review on the role of blended learning in the clinical education of health-care students, which identified only a few high quality studies on this topic, provided only rudimentary evidence that technology-enhanced teaching improves clinical competencies [ 32 ].

There are strengths, but also several limitations to our study.

The Red Eye: What Primary Care Physicians Need to Know

The chosen mixed methods study design is an appropriate way to evaluate a blended learning program, taking qualitative and quantitative information into account [ 33 ]. We not only evaluated student satisfaction, but also tried to quantify gain in skills and knowledge at both a group and at an individual level. One limitation is the relatively small number of participants included in the study. As the seminar is highly interactive, consisting mainly of work in small groups with tutors and simulation patients, no more than 18 students can be enrolled.

This is also one of the reasons why we could not compare the inverted classroom approach with a second group taught using traditional methods. This would have been desirable from a methodological point of view; however it was not feasible to divide the small group of participants any further. As we do not have long term follow up results e. It would have been desirable to perform an OSCE as pre- and post-test. However, from a practical point of view we did not consider it appropriate to confront students with the complex challenges of an OSCE at the start of the seminar.

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In this instance we had to balance methodological considerations versus the danger of frustrating the participating students right at the beginning of this elective course with an OSCE they would not at all be prepared for. This study shows that an inverted classroom model is well suited to teach the complex topic of differential diagnosis in primary care. While we perceived high student satisfaction, we could not prove whether the inverted classroom approach leads to a higher gain in skills and knowledge than traditional face-to-face teaching. Future research on our presented concept should therefore aim for a direct comparison of these two teaching approaches on gain in skills and knowledge, ideally in the form of a randomized controlled trial with an OSCE as test format.

Diagnostic strategies used in primary care. Umgang mit diagnostischer Unsicherheit in der Hausarztpraxis. Z Evid Fortbild Qual Gesundhwes. BMC Med Educ. Optimal sequencing of bedside teaching and computer-based learning: a randomised trial. Med Educ. Adv in Health Sci Educ. Blended learning approach improves teaching in a problem-based learning environment in orthopedics - a pilot study.

Romanov K, Nevgi A. Do medical students watch video clips in eLearning and do these facilitate learning? Med Teach. Shantikumar S. Is there a place for e-learning in clinical skills? Enhancing the quality of antibiotic prescribing in Primary Care: qualitative evaluation of a blended learning intervention. Abdominal pain, fever, peripheral neuropathy, tachycardia; may have only psychotic symptoms. Genetic enzyme defect; fasting and drugs affecting the cytochrome P system act as inducers.

Tay-Sachs disease, adult onset Dystonia, spinocerebellar signs; psychosis appears in one-third to one-half of patients. Dementia 16 , Alzheimer type. Prominent short-term memory loss; may have aggression, agitation, or paranoia; delusions may be mistaken for misperceptions because of cognitive changes. Nutritional deficiencies 32 - Confabulation, history of alcoholism, Korsakoff psychosis, older age, Wernicke encephalopathy. Psychotic symptoms in late childhood, early adolescence; in older adults, ataxia, glossitis, cogwheel rigidity, abdominal symptoms, persecutory delusions, hallucinations.

Complete blood count, Helicobacter pylori testing, intrinsic factor antibody testing, serum folate and vitamin B 12 testing. Ovarian teratoma Anti— N -methyl- d -aspartate receptor encephalitis may be associated with teratomas. Paraneoplastic limbic encephalitis CT, MRI, or electroencephalography; lumbar puncture; anti-Hu antibody testing; consider carcinoembryonic antigen and cancer antigen testing.

Pharmacologic conditions Table 3. Acute onset, agitation, altered mental status, delusions, hypertension, tachycardia, visual hallucinations. Psychiatric conditions 5 , 11 , 16 , 37 , Mania: decreased need for sleep, elevated or irritable mood, racing thoughts, risk taking. May present with depression; inquire about prior manic symptoms; selective serotonin reuptake inhibitors should be used with caution; lifetime prevalence of 0.

Differential Diagnosis in Primary Care, 4th Edition

Depression: anhedonia, changes in sleep and appetite, depressed mood, guilt, hopelessness, suicidality. Depression with psychotic features. Anhedonia, changes in sleep and appetite, delusions, depressed mood, guilt, hallucinations, hopelessness, paranoia, suicidality; may present with symptoms of panic and anxiety. Clinical diagnosis of exclusion. Psychotic disorder brief. Delusions and paranoia with hallucinations lasting one day to one month; if in peri- or postpartum phases, mother may have delusions that the baby is possessed, or hallucinations telling her to harm the baby.

Schizoaffective disorder. Auditory hallucinations, delusions, paranoia; overlap with schizophrenia and mood disorders; functional difficulty not a defining criterion. Auditory hallucinations, delusions, paranoia; decline in ability to work, or maintain relationships or self-care; a prodromal phase occurs when patients report peculiar perceptual experiences. First break often in late adolescence or early adulthood; prevalence of 0. Thyroid dysfunction. Information from references 5 , 11 , 16 , and 19 through Medical conditions associated with psychosis include autoimmune, endocrine, neurologic, and nutritional disorders.

Hallmark neurologic conditions include temporal lobe epilepsy, Parkinson disease, and Lewy body disease. A subacute onset of psychosis should raise suspicion for an oncologic cause, such as a steroid-producing tumor, space-occupying brain lesion, or paraneoplastic etiology.

Genetic or heritable diseases should be considered; for example, Huntington disease may first present with a psychotic episode. Information from references 18 , 37 , and Obtaining a history from a patient with psychotic symptoms may be challenging. Recognition of psychosis by the primary care physician is facilitated by prior knowledge of a patient's family, medical, and cultural history.

Individual cultures reflect a set of beliefs, values, and practices shared by members of a particular group. Delusional thinking and hallucinations should be considered within the patient's specific cultural context. What may appear delusional in one culture may be normal in another. Hallucinations relating to religious expressions may be accepted in certain groups. The temporal relationship and course of psychotic symptoms, as well as the patient's age, background, and general medical condition, may provide diagnostic clues.

An onset of psychosis may occur acutely after recreational drug use or as a later presentation in multiple sclerosis. Whenever possible, collateral information should be collected from family members. The social history should include recent stressors or significant changes in the patient's life, such as job loss, death of a significant other, educational stress, or other traumatic event.

Family history may provide clues to suggest a psychiatric diagnosis or heritable condition. Travel history may suggest exposure to infection, such as malaria. A history of multiple sex partners may suggest human immunodeficiency virus infection or syphilis. A dietary history is important to identify potential nutritional deficits, which are common in frail older persons. Niacin deficiency can be a consequence of severe eating disorders.

Occupational or environmental exposures should be noted. The physical examination should include a complete medical and mental status examination. Tendon reflexes, cranial nerve testing, and ophthalmologic examination are important if a brain lesion, infection, or metabolic disease is suspected. The mental status examination was reviewed in a previous article in American Family Physician. The patient's insight and judgment should be assessed; does the patient think he or she is ill?

Has the patient noticed changes in thinking? If yes, what changes?

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Direct inquiry about suicidal or homicidal thoughts and plans is essential to determine whether immediate referral or hospitalization is indicated. When diagnostic signs and symptoms suggest a medical condition, targeted laboratory tests can be obtained. If there is concern for an autoimmune cause, antinuclear antibody testing and determination of the erythrocyte sedimentation rate can be useful. Rare conditions, such as acute intermittent porphyria or adult Tay-Sachs disease, may be identified by urine testing for porphyrins, or serum testing for hexosaminidase A.

Emergency brain imaging is usually not required unless the patient presents with new, severe, unremitting headache; focal neurologic deficits; or a history of recent significant head trauma. Psychotic symptoms are debilitating and can be terrifying to patients and their families.

Prompt recognition of the etiology may improve treatment, consultation, and prognosis. The patient and family members can be given therapeutic support in the office, and provided with appropriate educational literature. If the patient expresses suicidal ideation or intent, or manifests symptoms of mania, immediate referral to emergency care is warranted. If the psychosis is secondary, the family physician has an opportunity to deliver timely intervention and management for acute causes, and to ameliorate symptoms by providing long-term patient- and family-centered support for more chronic conditions.

Any patient with a primary diagnosis of a psychotic disorder will benefit from close collaboration between behavioral health specialists and the primary care physician. Despite optimal treatment, patients with schizophrenia and other psychotic disorders often have deficits in social functioning, are unable to maintain employment, and lack appropriate housing.

The stigma of mental illness and poor mental health literacy compounds the challenges that patients face. Data Sources : PubMed, Agency for Healthcare Research and Quality reports, Essential Evidence Plus, the Cochrane database, and the National Guideline Clearinghouse were searched using the terms psychosis, primary care presentations, psychosis in children, postpartum psychosis, early psychosis, treatment of early psychosis, and specific medical conditions crossed with psychosis e.

Search dates: February through July Already a member or subscriber? Log in. Address correspondence to Kim S. Reprints are not available from the authors. Miller BF, Druss B. The role of family physicians in mental health care delivery in the United States: implications for health reform. J Am Board Fam Med. What is primary care mental health? Ment Health Fam Med. Accessed February 7, Lifetime prevalence of psychotic and bipolar I disorders in a general population.

Arch Gen Psychiatry. The prevalence of bipolar disorder in general primary care samples: a systematic review. Gen Hosp Psychiatry. Psychotic symptoms in an urban general medicine practice. Am J Psychiatry. Psychosis in children: diagnosis and treatment. Dialogues Clin Neurosci. Diagnostic challenges in children and adolescents with psychotic disorders. J Clin Psychiatry. Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study.

Evaluating the diagnostic accuracy of ultrasonography in differential diagnosis of adnexal tumours

Carter D, Kostaras X. Psychiatric disorders in pregnancy. BC Med J. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Identifying patients at risk of perinatal mood disorders. Atypical antipsychotic use in the treatment of psychosis in primary care. Seeman P. Glutamate and dopamine components in schizophrenia. J Psychiatry Neurosci.

The epidemiologic evidence linking autoimmune diseases and psychosis. Biol Psychiatry. Byrne P. Managing the acute psychotic episode. Kaplan PW. Delirium and epilepsy. Levenson JL. Psychosis in the medically ill. Primary Psychiatry. Primary hyperparathyroidism, cognition, and health-related quality of life. Ann Surg. Association of Huntington's disease and schizophrenia-like psychosis in a Huntington's disease pedigree.

Clin Pract Epidemiol Ment Health. Weintraub D, Hurtig HI. Presentation and management of psychosis in Parkinson's disease and dementia with Lewy bodies. Prevalence of Parkinson's disease-induced psychosis in a large U. J Neuropsychiatry Clin Neurosci. Mismanagement of Wilson's disease as psychotic disorder.

Adv Biomed Res. Anti-NMDA receptor encephalitis: an important differential diagnosis in psychosis.


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Br J Psychiatry. Kennedy PG, Chaudhuri A. Herpes simplex encephalitis. J Neurol Neurosurg Psychiatry. HIV infection and psychiatric illness. Afr J Psychiatry Johannesbg. Psychosis in neurosyphilis — clinical aspects and implications. Acute intermittent porphyria: psychosis as the only clinical manifestation. Isr J Psychiatry Relat Sci. Neuropsychiatric aspects of the adult variant of Tay-Sachs disease. Targum SD. Treating psychotic symptoms in elderly patients. Risk factors for psychosis secondary to temporal lobe epilepsy: a systematic review.

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Rapid resolution of delusional parasitosis in pellagra with niacin augmentation therapy. Paraneoplastic encephalitis, psychiatric symptoms, and hypoventilation in ovarian teratoma. Ann Neurol. Current approaches to the treatment of paraneoplastic encephalitis. Ther Adv Neurol Disord. Freudenreich O. Psychiatr Times. Diagnosing and managing psychosis in primary care. Heinrich TW, Grahm G. Hypothyroidism presenting as psychosis: myxedema madness revisited. Best practice: assessment of psychosis.

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Snyderman D, Rovner B. Mental status exam in primary care: a review.


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