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Ovitsh RK, Gupta S, Kusnoor A, Jackson JM, Roussel D, Mooney CJ, Pinto-Powell R, Appel JL, Mhaskar R, Gold J. Minding the gap: towards a shared clinical reasoning lexicon across the pre-clerkship/clerkship transition. MEDICAL EDUCATION ONLINE 2024; 29:2307715. [PMID: 38320116 PMCID: PMC10848998 DOI: 10.1080/10872981.2024.2307715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
Teaching and learning of clinical reasoning are core principles of medical education. However, little guidance exists for faculty leaders to navigate curricular transitions between pre-clerkship and clerkship curricular phases. This study compares how educational leaders in these two phases understand clinical reasoning instruction. Previously reported cross-sectional surveys of pre-clerkship clinical skills course directors, and clerkship leaders were compared. Comparisons focused on perceived importance of a number of core clinical reasoning concepts, barriers to clinical reasoning instruction, level of familiarity across the undergraduate medical curriculum, and inclusion of clinical reasoning instruction in each area of the curriculum. Analyses were performed using the Mann Whitney U test. Both sets of leaders rated lack of curricular time as the largest barrier to teaching clinical reasoning. Clerkship leaders also noted a lack of faculty with skills to teach clinical reasoning concepts as a significant barrier (p < 0.02), while pre-clerkship leaders were more likely to perceive that these concepts were too advanced for their students (p < 0.001). Pre-clerkship leaders reported a higher level of familiarity with the clerkship curriculum than clerkship leaders reported of the pre-clerkship curriculum (p < 0.001). As faculty transition students from the pre-clerkship to the clerkship phase, a shared understanding of what is taught and when, accompanied by successful faculty development, may aid the development of longitudinal, milestone-based clinical reasoning instruction.
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Affiliation(s)
- Robin K. Ovitsh
- Department of Pediatrics, Downstate Health Sciences University College of Medicine, Brooklyn, NY, USA
| | - Shanu Gupta
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Anita Kusnoor
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer M. Jackson
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Danielle Roussel
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Christopher J. Mooney
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Roshini Pinto-Powell
- Department of Medicine and Medical Education, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Joel L. Appel
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, University of South Florida College of Medicine, Tampa, FL, USA
| | - Jonathan Gold
- Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI, USA
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Madduri GB, Torwekar EL, Demirel S, Durham M, Hauff KI, Kaul R, Nichols T, Ravid NL, Shaner MA, Rassbach CE. CRISP: An Inpatient Pediatric Curriculum for Family Medicine Residents Using Clinical Reasoning and Illness Scripts. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2024; 20:11393. [PMID: 38524942 PMCID: PMC10957791 DOI: 10.15766/mep_2374-8265.11393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/04/2024] [Indexed: 03/26/2024]
Abstract
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.
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Affiliation(s)
- Gayatri B. Madduri
- Assistant Professor, Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine; Family Medicine Inpatient Pediatrics Rotation Director, John Muir Medical Center
| | - Elizabeth L. Torwekar
- GME Director of Pediatric Education and Pediatric Hospitalist, Department of Pediatrics, Randall Children's Hospital, Legacy Health
| | - Shaban Demirel
- Vice President of Research, Legacy Research Institute, and Director of Clinical Research, Legacy Health
| | - Megan Durham
- Clinical Instructor, Department of Pediatrics, Randall Children's Hospital, Legacy Health
| | - Kimberlee I. Hauff
- Associate Professor, Department of Family Medicine, University of Washington; Family Medicine Inpatient Pediatrics Rotation Director, Swedish Medical Center
| | - Rajat Kaul
- Associate Professor, Division of Hospital Medicine, Department of Pediatrics, Ebeid Children's Hospital; Pediatric Clerkship Director, University of Toledo College of Medicine and Life Sciences
| | - Tristan Nichols
- Assistant Professor, Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine; Family Medicine Inpatient Pediatrics Rotation Director, John Muir Medical Center
| | - Noga L. Ravid
- Assistant Professor, Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine; Chair, Department of Pediatrics, John Muir Medical Center
| | - Mason A. Shaner
- Third-Year Medical Student, University of Michigan Medical School
| | - Caroline E. Rassbach
- Professor, Division of Pediatric Hospital Medicine, Department of Pediatrics, and Program Director, Pediatrics Residency and Pediatrics-Anesthesiology Residency, Stanford University School of Medicine
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Lai JH, Cheng KH, Wu YJ, Lin CC. Assessing clinical reasoning ability in fourth-year medical students via an integrative group history-taking with an individual reasoning activity. BMC MEDICAL EDUCATION 2022; 22:573. [PMID: 35883069 PMCID: PMC9316809 DOI: 10.1186/s12909-022-03649-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 07/18/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The most important factor in evaluating a physician's competence is strong clinical reasoning ability, leading to correct principal diagnoses. The process of clinical reasoning includes history taking, physical examinations, validating medical records, and determining a final diagnosis. In this study, we designed a teaching activity to evaluate the clinical reasoning competence of fourth-year medical students. METHODS We created five patient scenarios for our standardized patients, including hemoptysis, abdominal pain, fever, anemia, and chest pain. A group history-taking with individual reasoning principles was implemented to teach and evaluate students' abilities to take histories, document key information, and arrive at the most likely diagnosis. Residents were trained to act as teachers, and a post-study questionnaire was employed to evaluate the students' satisfaction with the training activity. RESULTS A total of 76 students, five teachers, and five standardized patients participated in this clinical reasoning training activity. The average history-taking score was 64%, the average key information number was 7, the average diagnosis number was 1.1, and the average correct diagnosis rate was 38%. Standardized patients presenting with abdominal pain (8.3%) and anemia (18.2%) had the lowest diagnosis rates. The scenario of anemia presented the most difficult challenge for students in history taking (3.5/5) and clinical reasoning (3.5/5). The abdominal pain scenario yielded even worse results (history taking: 2.9/5 and clinical reasoning 2.7/5). We found a correlation in the clinical reasoning process between the correct and incorrect most likely diagnosis groups (group history-taking score, p = 0.045; key information number, p = 0.009 and diagnosis number, p = 0.004). The post-study questionnaire results indicated significant satisfaction with the teaching program (4.7/5) and the quality of teacher feedback (4.9/5). CONCLUSIONS We concluded that the clinical reasoning skills of fourth-year medical students benefited from this training course, and the lower correction of the most likely diagnosis rate found with abdominal pain, anemia, and fever might be due to a system-based teaching modules in fourth-year medical students; cross-system remedial reasoning auxiliary training is recommended for fourth-year medical students in the future.
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Affiliation(s)
- Jian-Han Lai
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
- Department of Medical Education, MacKay Memorial Hospital, No. 92, Sec. 2, Chung-Shan North Road, Taipei, Taiwan
- MacKay Medicine, Nursing and Management College, Taipei, Taiwan
| | - Kuan-Hao Cheng
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
- Department of Medical Education, MacKay Memorial Hospital, No. 92, Sec. 2, Chung-Shan North Road, Taipei, Taiwan
| | - Yih-Jer Wu
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
- Department of Medical Education, MacKay Memorial Hospital, No. 92, Sec. 2, Chung-Shan North Road, Taipei, Taiwan
| | - Ching-Chung Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.
- Department of Medical Education, MacKay Memorial Hospital, No. 92, Sec. 2, Chung-Shan North Road, Taipei, Taiwan.
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Stafford M, Johnson B, Hessler D. A Systematic Approach to Working With Medical Learners in Difficulty: A Faculty Development Workshop. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:10872. [PMID: 32175468 PMCID: PMC7062539 DOI: 10.15766/mep_2374-8265.10872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 09/07/2019] [Indexed: 06/10/2023]
Abstract
Introduction For medical educators, applying a systematic approach to working with struggling learners (learners in difficulty) can improve faculty success and satisfaction with the remediation process. Use of the familiar SOAP diagnostic framework can ensure that faculty develop a thorough differential diagnosis and target their interventions to address underlying issues affecting learner success. Methods We developed a workshop to teach medical education faculty essential skills for supporting learners in difficulty. Teaching methods included didactic presentation, large-group discussion, and small-group work with role-plays. Over three 2-hour sessions, participants learned to assess a learner in difficulty, develop an initial remediation plan, and evaluate their learning system with the goal of improving support to learners in difficulty. Evaluation included pre- and postsession assessment of learner self-perceived confidence and skill with working with struggling learners, as well as brief postsession evaluation. Results Ninety-nine faculty participated in the Learners in Difficulty workshop over 7 years. Participants' overall rating of the workshop was 4.9 (1 = poor, 5 = outstanding). Pre- and postworkshop evaluation showed a statistically significant increase in perceived self-confidence to "Meet the needs of a struggling learner," from an average of 4.4 to 7.6 on a 10-point scale (mean Δ = 3.2; 95% confidence interval, 2.6-3.8; p < .001). Discussion This workshop provides a stepwise approach to working with learners in difficulty and assessing participants' educational systems to identify strengths and weaknesses. Evaluations indicated participants felt more confident in their ability to engage in this topic following completion of the workshop.
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Affiliation(s)
- Margaret Stafford
- Associate Professor, Department of Family and Community Medicine, University of California, San Francisco, School of Medicine
- Lead, Family Medicine Faculty Development Fellowship, University of California, San Francisco, School of Medicine
| | - Brian Johnson
- Program Director, Contra Costa Family Medicine Residency Program
- Director, Family Medicine Faculty Development Fellowship, University of California, San Francisco, School of Medicine
| | - Danielle Hessler
- Associate Professor, Department of Family and Community Medicine, University of California, San Francisco, School of Medicine
- Vice Chair of Research, Department of Family and Community Medicine, University of California, San Francisco, School of Medicine
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Ohmer M, Durning SJ, Kucera W, Nealeigh M, Ordway S, Mellor T, Mikita J, Howle A, Krajnik S, Konopasky A, Ramani D, Battista A. Clinical Reasoning in the Ward Setting: A Rapid Response Scenario for Residents and Attendings. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2019; 15:10834. [PMID: 31773062 PMCID: PMC6869982 DOI: 10.15766/mep_2374-8265.10834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 05/21/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION There is a need for educational resources supporting the practice and assessment of the complex processes of clinical reasoning in the inpatient setting along a continuum of physician experience levels. METHODS Using participatory design, we created a scenario-based simulation integrating diagnostic ambiguity, contextual factors, and rising patient acuity to increase complexity. Resources include an open-ended written exercise and think-aloud reflection protocol to elicit diagnostic and management reasoning and reflection on that reasoning. Descriptive statistics were used to analyze the initial implementation evaluation results. RESULTS Twenty physicians from multiple training stages and specialties (interns, residents, attendings, family physicians, internists, surgeons) underwent the simulated scenario. Participants engaged in clinical reasoning processes consistent with the design, considering a total of 19 differential diagnoses. Ten participants provided the correct leading diagnosis, tension pneumothorax, with an additional eight providing pneumothorax and all participants offering relevant supporting evidence. There was also good evidence of management reasoning, with all participants either performing an intervention or calling for assistance and reflecting on management plans in the think-aloud. The scenario was a reasonable approximation of clinical practice, with a mean authenticity rating of 4.15 out of 5. Finally, the scenario presented adequate challenge, with interns and residents rating it as only slightly more challenging (means of 7.83 and 7.17, respectively) than attendings (mean of 6.63 out of 10). DISCUSSION Despite the challenges of scenario complexity, evaluation results indicate that this resource supports the observation and analysis of diagnostic and management reasoning of diverse specialties from interns through attendings.
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Affiliation(s)
- Megan Ohmer
- Research Assistant, Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Steven J. Durning
- Professor, Department of Medicine and Pathology, Uniformed Services University of the Health Sciences
- Director, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Walter Kucera
- Resident, Department of Surgery, Walter Reed National Military Medical Center
| | - Matthew Nealeigh
- Resident, Department of Surgery, Walter Reed National Military Medical Center
| | - Sarah Ordway
- Fellow, Department of Internal Medicine, Division of Gastroenterology, Walter Reed National Military Medical Center
| | - Thomas Mellor
- Fellow, Department of Internal Medicine, Division of Gastroenterology, Naval Medical Center San Diego
| | - Jeffery Mikita
- Chief, Department of Simulation, Walter Reed National Military Medical Center
- Program Director, Department of Internal Medicine, Division of Pulmonology and Critical Care Medicine, Walter Reed National Military Medical Center
- Associate Professor, Department of Medicine, Uniformed Services University of the Health Sciences
| | - Anna Howle
- Simulation Educator, Department of Simulation, Walter Reed National Military Medical Center
| | - Sarah Krajnik
- Simulation Educator, Department of Simulation, Walter Reed National Military Medical Center
| | - Abigail Konopasky
- Assistant Professor, Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Divya Ramani
- Research Assistant, Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Alexis Battista
- Assistant Professor, Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
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Battista A, Konopasky A, Ramani D, Ohmer M, Mikita J, Howle A, Krajnik S, Torre D, Durning SJ. Clinical Reasoning in the Primary Care Setting: Two Scenario-Based Simulations for Residents and Attendings. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2018; 14:10773. [PMID: 30800973 PMCID: PMC6346281 DOI: 10.15766/mep_2374-8265.10773] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 10/12/2018] [Indexed: 06/09/2023]
Abstract
Introduction We describe the development and implementation of tools medical educators or researchers can use for developing or analyzing residents' through attending physicians' clinical reasoning in an outpatient clinic setting. The resource includes two scenario-based simulations (i.e., diabetes, angina), implementation support materials, an open-ended postencounter form, and a think-aloud reflection protocol. Method We designed two scenarios with potential case ambiguity and contextual factors to add complexity for studying clinical reasoning. The scenarios are designed to be used prior to an open-ended written exercise and a think-aloud reflection to elicit reasoning and reflection. We report on their implementation in a research context but developed them to be used in both educational and research settings. Results Twelve physicians (five interns, three residents, and four attendings) considered between three and six differential diagnoses (M = 4.0) for the diabetes scenario and between three and nine differentials (M = 4.3) for angina. In think-aloud reflections, participants reconsidered their thinking between zero and 14 times (M = 3.5) for diabetes and zero and 11 times (M = 3.3) for angina. Cognitive load scores ranged from 4 to 8 (out of 10; M = 6.2) for diabetes and 5 to 8 (M = 6.6) for angina. Participants rated scenario authenticity between 4 and 5 (out of 5). Discussion The potential case content ambiguity, along with the contextual factors (e.g., patient suggesting alternative diagnoses), provides a complex environment in which to explore or teach clinical reasoning.
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Affiliation(s)
- Alexis Battista
- Assistant Professor, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Abigail Konopasky
- Assistant Professor, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Divya Ramani
- Research Associate, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Megan Ohmer
- Research Associate, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Jeffrey Mikita
- Chief, Department of Simulation, Walter Reed National Military Medical Center
| | - Anna Howle
- Simulation Educator, Department of Medical Simulation, Walter Reed National Military Medical Center
| | - Sarah Krajnik
- Nurse Educator, Department of Simulation, Walter Reed National Military Medical Center
| | - Dario Torre
- Associate Director, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Steven J. Durning
- Director, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
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