You too can teach clinical reasoning!

CRISP: An Inpatient Pediatric Curriculum for Family Medicine Residents Using Clinical Reasoning and Illness Scripts

Introduction

Clinical reasoning enables safe patient care and is an important competency in medical education but can be challenging to teach. Illness scripts facilitate clinical reasoning but have not been used to create pediatric curricula.

Methods

We created CRISP (Clinical Reasoning with Illness Scripts in Pediatrics), a curriculum comprising four 1-hour learning sessions that deliberately incorporated clinical reasoning concepts and illness scripts to organize how four common chief complaints were taught to family medicine residents on inpatient pediatric rotations. We performed a multisite curriculum evaluation project over 6 months with family medicine residents at four institutions to assess whether the use of clinical reasoning concepts to structure CRISP was feasible and acceptable for learners and instructors and whether the use of illness scripts increased knowledge of four common pediatric chief complaints.

Results

For all learning sessions, family medicine residents and pediatric hospitalists agreed that CRISP's format was preferable to traditional didactic lectures. Pre-/posttest scores showed statistically significant increases in family medicine resident knowledge (respiratory distress [n = 42]: pretest, 72%, posttest, 92%; abdominal pain [n = 44]: pretest, 82%, posttest, 96%; acute febrile limp [n = 44]: pretest, 68%, posttest, 81%; well-appearing febrile infant [n = 42]: pretest, 58%, posttest, 73%; ps < .05).

Discussion

By using clinical reasoning concepts and illness script comparison to structure a pediatric curriculum, CRISP represents a novel instructional approach that can be used by pediatric hospitalists to increase family medicine resident knowledge about diagnoses associated with common pediatric chief complaints.

Educating for adaptive expertise: case examples along the medical education continuum

Adaptive expertise represents the combination of both efficient problem-solving for clinical encounters with known solutions, as well as the ability to learn and innovate when faced with a novel challenge. Fostering adaptive expertise requires careful approaches to instructional design to emphasize deeper, more effortful learning. These teaching strategies are time-intensive, effortful, and challenging to implement in health professions education curricula. The authors are educators whose missions encompass the medical education continuum, from undergraduate through to organizational learning. Each has grappled with how to promote adaptive expertise development in their context. They describe themes drawn from educational experiences at these various learner levels to illustrate strategies that may be used to cultivate adaptive expertise.At Vanderbilt University School of Medicine, a restructuring of the medical school curriculum provided multiple opportunities to use specific curricular strategies to foster adaptive expertise development. The advantage for students in terms of future learning had to be rationalized against assessments that are more short-term in nature. In a consortium of emergency medicine residency programs, a diversity of instructional approaches was deployed to foster adaptive expertise within complex clinical learning environments. Here the value of adaptive expertise approaches must be balanced with the efficiency imperative in clinical care. At Mayo Clinic, an existing continuous professional development program was used to orient the entire organization towards an adaptive expertise mindset, with each individual making a contribution to the shift.The different contexts illustrate both the flexibility of the adaptive expertise conceptualization and the need to customize the educational approach to the developmental stage of the learner. In particular, an important benefit of teaching to adaptive expertise is the opportunity to influence individual professional identity formation to ensure that clinicians of the future value deeper, more effortful learning strategies throughout their careers.

Clinical reasoning: exploring its characteristics and enhancing its learning

Clinical reasoning is an extensive and intricate field, dealing with the process of thinking and decision making in practice. Its study can be quite challenging because it is context and task dependent. Educational frameworks such as the conscious competence model and the dual process reasoning model have been developed to help its understanding. To enhance the learning of clinical reasoning, there are significant areas that can be targeted through learning processes. These include knowledge adequacy; ability to gather appropriate patient data; use of proper reasoning strategies to address specific clinical questions; and the ability to reflect and evaluate on decisions taken, together with the role of the wider practice community and the activity of professional socialisation. This article explores the characteristics of clinical reasoning and delves deeper into the various strategies that prove useful for learning.

Effects of reflection and immediate feedback to improve clinical reasoning of medical students in the assessment of dermatologic conditions: a randomised controlled trial

BACKGROUND

There are few studies that directly compared different interventions to improve medical students' clinical reasoning for dermatologic conditions.

OBJECTIVE

To investigate the effectiveness of adding practice with reflection and immediate feedback on traditional dermatology electives in improving medical students' ability in evaluating skin lesions.

METHODS

The participants were fourth-year medical students of Seoul National University College of Medicine, Korea, who were enrolled to take a 2-week dermatology elective course (n = 87). Students were assigned to one of the three educational interventions: 2-h training involving 10 written clinical cases (experimental); 1-h lecture and 1-h outpatient clinic (lecture); and 2-h outpatient clinic (no intervention). Before and at the end of rotation, diagnostic accuracy was estimated using 20 written clinical cases with photographs (10 novel cases presented in diagnostic training [training set], 10 cases with diagnoses not included in training [control set]).

RESULTS

There was a significant interaction effect of intervention×set×time. A post hoc analysis indicated that the students in the experimental group outperformed students in the other two groups only in the training set of the final tests; after completing the 2-week rotation, for the training set, the mean score was higher in the experimental group (7.5 ± 1.3) than in the lecture (5.7 ± 1.6) and no intervention (5.6 ± 1.3) groups, producing an effect size of 1.2 standard deviation (SD) and 1.5 SD, respectively.

CONCLUSION

Practicing written clinical cases with reflection and feedback is superior to a lecture-based approach and yields additional benefits to a dermatology elective, thereby enhancing medical students' ability to accurately diagnose skin lesions.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03472001. Registered 21 March 2018.

Theory-guided teaching: Implementation of a clinical reasoning curriculum in residents

Introduction: Educators have theorized that interventions grounded in dual process theory (DPT) and script theory (ST) may improve the diagnostic reasoning process of physicians but little empirical evidence exists. Methods: In this quasi-experimental study, we assessed the impact of a clinical reasoning (CR) curriculum grounded in DPT and ST on medicine residents participating in one of three groups during a 6-month period: no, partial, or full intervention. Residents completed the diagnostic thinking inventory (DTI) at baseline and 6 months. At 6 months, participants also completed a post-survey assessing application of concepts to cases. Results: There was a significant difference between groups in application of concepts (no intervention 1.6 (0.65) compared to partial 2.3 (0.81) and full 2.2 (0.91), p = 0.05), as well as describing cases in problem representation format (no intervention 1.2 (0.38) and partial 1.5 (0.55) compared to full 2.1 (0.93), p = 0.004). There was no significant difference in change in DTI scores (no intervention 7.0 (16.3), partial 8.8 (9.8), full 7.8 (12.0)). Conclusions: Residents who participated in a CR curriculum grounded in DPT and ST were effective in applying principles of CR in cases from their practice. To our knowledge, this is the first workplace-based CR educational intervention study showing differences in the reasoning process residents apply to patients.

Diagnosing and Remediating Clinical Reasoning Difficulties: A Faculty Development Workshop

INTRODUCTION

Clinical reasoning is a complex cognitive process that involves multiple steps. Diagnosing and remediating clinical reasoning difficulties requires faculty to have an understanding of the cognitive theory behind clinical reasoning, familiarity with terminology, and a framework to identify different domains of struggle in their learners. Published resources on faculty development to diagnose and remediate clinical reasoning difficulties are limited. We created and implemented a workshop to assist faculty in developing these skills based on the five-domain framework described by Audétat, Laurin, and Sanche. This workshop provides all the materials needed to replicate this training with faculty at other institutions.

METHODS

The workshop consists of a didactic component and case-based active learning in small groups. Each case focuses on different domains of clinical reasoning difficulties and targets different learner levels (preclinical medical students through residents). The workshop was given in multiple venues in 2016 and 2017.

RESULTS

Participants reported the session was valuable (4.71/5.0), the facilitators were effective (4.5/5.0), and the objectives were met (4.28/5.0). They highlighted the strengths of the interactive format, the framework to diagnose and remediate clinical reasoning difficulties, and the excellent take-home resources. They suggested more time for the workshop, revision of cases to better highlight difficulties, and refinement of instructions to approach the cases. These suggestions were incorporated into the current iteration of the workshop.

DISCUSSION

We successfully implemented a workshop for diagnosing and remediating clinical reasoning difficulties in multiple venues. The sessions were diverse in terms of faculty participants and learner groups addressed.

Nurse practitioner malpractice data: Informing nursing education

BACKGROUND

Nurse practitioners (NPs) are often identified in medical malpractice claims. However, the use of malpractice data to inform the development of nursing curriculum is limited. The purpose of this study is to examine medical errors committed by NPs.

METHODS

Using National Practitioner Data Bank public use data, years 1990 to 2014, NP malpractice claims were classified by event type, patient outcome, setting, and number of practitioners involved.

RESULTS

The greatest proportion of malpractice claims involving nurse practitioners were diagnosis related (41.46%) and treatment related (30.79%). Severe patient outcomes most often occurred in the outpatient setting. Nurse practitioners were independently responsible for the event in the majority of the analyzed claims.

CONCLUSION

Moving forward, nurse practitioner malpractice data should be continuously analyzed and used to inform the development of nurse practitioner education standards and graduate program curriculum to address areas of clinical weakness and improve quality of care and patient safety.

How to improve the teaching of clinical reasoning: a narrative review and a proposal

CONTEXT

The development of clinical reasoning (CR) in students has traditionally been left to clinical rotations, which, however, often offer limited practice and suboptimal supervision. Medical schools begin to address these limitations by organising pre-clinical CR courses. The purpose of this paper is to review the variety of approaches employed in the teaching of CR and to present a proposal to improve these practices.

METHODS

We conducted a narrative review of the literature on teaching CR. To that end, we searched PubMed and Web of Science for papers published until June 2014. Additional publications were identified in the references cited in the initial papers. We used theoretical considerations to characterise approaches and noted empirical findings, when available.

RESULTS

Of the 48 reviewed papers, only 24 reported empirical findings. The approaches to teaching CR were shown to vary on two dimensions. The first pertains to the way the case information is presented. The case is either unfolded to students gradually - the 'serial-cue' approach - or is presented in a 'whole-case' format. The second dimension concerns the purpose of the exercise: is its aim to help students acquire or apply knowledge, or is its purpose to teach students a way of thinking? The most prevalent approach is the serial-cue approach, perhaps because it tries to directly simulate the diagnostic activities of doctors. Evidence supporting its effectiveness is, however, lacking. There is some empirical evidence that whole-case, knowledge-oriented approaches contribute to the improvement of students' CR. However, thinking process-oriented approaches were shown to be largely ineffective.

CONCLUSIONS

Based on research on how expertise develops in medicine, we argue that students in different phases of their training may benefit from different approaches to the teaching of CR.

Educational strategies for improving clinical reasoning

Clinical reasoning serves as a crucial skill for all physicians regardless of their area of expertise. Helping trainees develop effective and appropriate clinical reasoning abilities is a central aim of medical education. Teaching clinical reasoning however can be a very difficult challenge for practicing physicians. Better understanding of the different cognitive processes involved in physician clinical reasoning provides a foundation from which to guide learner development of effective reasoning skills, while pairing assessment of learner reasoning abilities with understanding of different improvement strategies offers the opportunity to maximize educational efforts for learners. Clinical reasoning errors often can occur as a result of one of four problems in trainees as well as practicing physicians; inadequate knowledge, faulty data gathering, faulty data processing, or faulty metacognition. Educators are encouraged to consider at which point a given learner's reasoning is breaking down. Experimentation with different strategies for improving clinical reasoning can help address learner struggles in each of these domains. In this chapter, various strategies for improving reasoning related to knowledge acquisition, data gathering, data processing, and clinician metacognition will be discussed. Understanding and gaining experience using the different educational strategies will provide practicing physicians with a toolbox of techniques for helping learners improve their reasoning abilities.