Following the Script: An Exploratory Study of the Therapeutic Reasoning Underlying Physicians' Choice of Antimicrobial Therapy

Perceptions of antibiotic resistance among hospital healthcare professionals in high-income countries: A systematic review of causes, consequences, and solutions

OBJECTIVE

Antibiotic resistance (ABR) is a major threat to public health. Hospital healthcare professionals are important stakeholders in curbing ABR. To be able to encourage healthcare professionals to act against ABR, information on their perceptions is needed. Yet, summary evidence on how healthcare professionals perceive ABR causes, consequences, and solutions is outdated. This review aims to elucidate these perceptions.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, and CINAHL for literature published until July 6th, 2022, and used Web of Science and Scopus to identify reports citing included studies. Reports of quantitative original research from high-income countries were included if they investigated hospital healthcare professionals' perceptions about ABR. Descriptive data and data on perceptions about causes, consequences, and solutions regarding ABR were extracted. PROSPERO registration: CRD42022359249.

RESULTS

The database search and citation tracking yielded 13,551 and 694 papers respectively. Forty-eight reports from 46 studies were included in the review. These studies were performed between 1999 and 2023 and included between 8 and 1362 participants. Healthcare professionals perceived ABR as a problem that is more severe nationally than locally and they primarily recognize ABR as a distant and abstract problem. Studies mostly concurred on prescribing behavior as a cause and a solution for ABR, while external causes and solutions (e.g., in agriculture) elicited less agreement.

CONCLUSIONS

Studies with a primary focus on the perceptions of healthcare professionals about ABR are limited. Healthcare professionals perceive prescribing behavior as a major cause of ABR and a focus area for ABR solutions.

How to change the course: practical aspects of implementing shorter is better

BACKGROUND

Based on multiple randomized-controlled clinical trials, shorter antibiotic courses are equally effective as traditional longer courses for many types of infections. However, longer courses are still being used widely in the clinical practice.

OBJECTIVES

To describe four components involved in the successful implementation of shorter antibiotic courses in our health care institutions, including an academic, public hospital and a community hospital staffed primarily by private practitioners.

SOURCES

Clinical trials and peer-reviewed publications.

CONTENT

We provide practical advice on how to support the change in clinical practice to shorten antibiotic duration. Specifically, we list the steps that we have successfully used to develop and implement an institutional practice change regarding the duration of antibiotic therapy: (a) establishing consensus documents outlining a data-driven expected practice for using antibiotics, (b) antibiotic stewardship programme support, (c) provider education, and (d) reinforcing behaviour through psychological and other tools. The implementation of these processes has successfully led to shorter antibiotic courses and decreased antibiotic use in our diverse practice settings.

IMPLICATIONS

Intentional improvement in decreasing the duration of antibiotic therapy can be achieved by a specific antibiotic stewardship programme strategy and tactics. The implementation of shorter antibiotic courses has effects at individual and societal levels in an era of increasing antibacterial resistance and health care costs.

The PEST (Pathology, Epidemiology, Severity, Treatment) approach to optimizing antimicrobial therapy

BACKGROUND

Selecting an empiric antimicrobial regimen can be difficult for early learners and misuse of antibiotics can lead to adverse events and antimicrobial resistance. There have been few interventions that have focused on improving antibiotic decision making, as a form of therapeutic reasoning, for post-graduate trainees. We describe here an approach to aid internal medicine interns in their therapeutic reasoning, particularly when it comes to diagnosing and empirically treating infections.

METHODS

The PEST (pathology, epidemiology, severity, treatment) model was created as a four-step approach to therapeutic reasoning and choosing an appropriate antimicrobial regimen for a given infectious disease syndrome. In February 2020, we conducted two independent teaching sessions for interns on the PEST approach. We assessed pre-and post-teaching responses to five clinical vignette-based questions. Results were presented as a percentage of interns who chose an appropriate antibiotic and provided sufficient therapeutic reasoning as defined by using at least three out of the four PEST criteria. Statistical analysis occurred via Fischer's exact test to determine the level of statistical significance between responses.

RESULTS

Twenty-seven interns participated in the activity. At baseline, several interns had incorporated aspects of the PEST approach in their pre-teaching responses. Ten interns commented on the usefulness of such a systematic approach. While there was no statistically significant difference in antibiotic selection, the teaching session demonstrated a trend towards significance in improving therapeutic reasoning as defined by the PEST strategy.

CONCLUSION

Our results suggested an improvement in using a structured cognitive tool such as the PEST approach to reinforce therapeutic reasoning, but the method did little to improve antibiotic selection. Some interns used select "PEST" concepts prior to the intervention suggesting that the PEST approach may enhance prior knowledge or clinical reasoning skills. Continued incorporation of the PEST approach using a case-based framework may solidify conceptual and practical knowledge of antimicrobial selection. Further studies are needed to assess the impact of such teaching interventions.

The future of teaching management reasoning: important questions and potential solutions

Management reasoning is distinct from but inextricably linked to diagnostic reasoning in the iterative process that is clinical reasoning. Complex and situated, management reasoning skills are distinct from diagnostic reasoning skills and must be developed in order to promote cogent clinical decisions. While there is growing interest in teaching management reasoning, key educational questions remain regarding when it should be taught, how it can best be taught in the clinical setting, and how it can be taught in a way that helps mitigate implicit bias. Here, we describe several useful tools to structure teaching of management reasoning across learner levels and educational settings. The management script provides a scaffold for organizing knowledge around management and can serve as a springboard for discussion of uncertainty, thresholds, high-value care, and shared decision-making. The management pause reserves space for management discussions and exploration of a learner's reasoning. Finally, the equity reflection invites learners to examine management decisions from a health equity perspective, promoting the practice of metacognition around implicit bias. These tools are easily deployable, and - when used regularly - foster a learning environment primed for the successful teaching of management reasoning.

"Cephalgia" or "migraine"? Solving the headache of assessing clinical reasoning using natural language processing

In this op-ed, we discuss the advantages of leveraging natural language processing (NLP) in the assessment of clinical reasoning. Clinical reasoning is a complex competency that cannot be easily assessed using multiple-choice questions. Constructed-response assessments can more directly measure important aspects of a learner's clinical reasoning ability, but substantial resources are necessary for their use. We provide an overview of INCITE, the Intelligent Clinical Text Evaluator, a scalable NLP-based computer-assisted scoring system that was developed to measure clinical reasoning ability as assessed in the written documentation portion of the now-discontinued USMLE Step 2 Clinical Skills examination. We provide the rationale for building a computer-assisted scoring system that is aligned with the intended use of an assessment. We show how INCITE's NLP pipeline was designed with transparency and interpretability in mind, so that every score produced by the computer-assisted system could be traced back to the text segment it evaluated. We next suggest that, as a consequence of INCITE's transparency and interpretability features, the system may easily be repurposed for formative assessment of clinical reasoning. Finally, we provide the reader with the resources to consider in building their own NLP-based assessment tools.

Management reasoning scripts: Qualitative exploration using simulated physician-patient encounters

INTRODUCTION

Management reasoning is distinct from diagnostic reasoning and remains incompletely understood. The authors sought to empirically investigate the concept of management scripts.

METHODS

In November 2020, 4 investigators each reviewed 10 video clips of simulated outpatient physician-patient encounters, and used a coding form to document observations about management reasoning. The team used constant comparative analysis to integrate empirically-grounded insights with theories related to cognitive scripts and Type 1/Type 2 thinking.

RESULTS

Management scripts are precompiled conceptual knowledge structures that represent and connect management options and clinician tasks in a temporal or logical sequence. Management scripts appear to differ substantially from illness scripts. Management scripts varied in quality (in content, sequence, flexibility, and fluency) and generality. The authors empirically identified six key features (components) of management scripts: the problem (diagnosis); management options; preferences, values, and constraints; education needs; interactions; and encounter flow. The authors propose a heuristic framework describing script activation, selection, instantiation with case-specific details, and application to guide development of the management plan. They further propose that management reasoning reflects iterative, back-and-forth involvement of both Type 1 (non-analytic, effortless) and Type 2 (analytic, effortful) thinking. Type 1 thinking likely influences initial script activation, selection, and initial instantiation. Type 2 increasingly influences subsequent script revisions, as activation, selection, and instantiation become more deliberate (effortful) and more hypothetical (involving mental simulation).

DISCUSSION

Management scripts constitute a key feature of management reasoning, and could represent a new target for training in clinical reasoning (distinct from illness scripts).

Investigating pharmacy students' therapeutic decision-making with respect to antimicrobial stewardship cases

BACKGROUND

Antimicrobial stewardship programs (ASPs) play a big role in minimizing antimicrobial resistance. Pharmacists are essential members of the health care team and in order for them to fulfill roles on ASP teams and become antimicrobial stewards, they must be prepared adequately by pharmacy schools prior to entry into actual practice. Although programming has been implemented into entry-to-practice programs worldwide, little is known about how students interpret antimicrobial stewardship (AMS) data and arrive at clinical decisions. We aimed to explore students' cognitive processes and determine how they formulate therapeutic decisions when presented with AMS cases.

METHODS

This was a qualitative study conducted using a case study approach, in which a sample (n=20) of pharmacy students was recruited to interpret AMS cases. Semi-structured 1-on-1 interviews were arranged with each participant. A think-aloud procedure with verbal protocol analysis was adopted to determine students' decision-making processes. Thematic analysis was used to interpret themes from the interview data.

RESULTS

Two themes were interpreted from the data: students' focus and students' approach to case interpretation. Students' focus relates to external factors students consider when interpreting AMS case data and use to make and justify therapeutic decisions including patient-centered factors, drug-related factors, AMS interventions, and pharmacist's role. Students' clinical reasoning describes the approach that students use to interpret the data and the decision-making processes they employ to arrive at a clinical decision including a systematic approach versus non-systematic approach.

CONCLUSIONS

Students vary in their focus and the cognitive strategies used to interpret AMS cases. Findings support the notion that clinical reasoning and decision-making should be explicitly taught in pharmacy curricula, in order to help students become aware of their own cognitive processes and decision-making abilities.

How to Keep Training-After Residency Training

Lifelong learning in medicine is an important skill and ethical obligation, but many residents do not feel prepared to be effective self-directed learners when training ends. The learning sciences offer evidence to guide self-directed learning, but these insights have not been integrated into a practical and actionable plan for residents to improve their clinical knowledge and reasoning. We encourage residents to establish a self-directed learning plan, just as an athlete employs a training plan in the pursuit of excellence. We highlight four evidence-based learning principles (spaced practice, mixed practice, retrieval practice, and feedback) and four training strategies comprising a weekly training plan: case tracking, simulated cases, quizzing, and new evidence integration. We provide tips for residents to implement and refine their approach and discuss how residency programs can foster these routines and habits. By optimizing their scarce self-directed learning time with a training plan, residents may enhance patient care and their career satisfaction through their pursuit of clinical mastery.