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Poluch M, Feingold-Link J, Ankam N, Kilpatrick J, Cameron K, Chandra S, Doty A, Klein M, McCarthy D, Rising K, Salzman D, Ziring D, Papanagnou D. I Don't Have a Diagnosis for You: Preparing Medical Students to Communicate Diagnostic Uncertainty in the Emergency Department. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2022; 18:11218. [PMID: 35178469 PMCID: PMC8814030 DOI: 10.15766/mep_2374-8265.11218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/27/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Diagnostic uncertainty abounds in medicine, and communication of that uncertainty is critical to the delivery of high-quality patient care. While there has been training in communicating diagnostic uncertainty directed towards residents, a gap remains in preparing medical students to understand and communicate diagnostic uncertainty. We developed a session to introduce medical students to diagnostic uncertainty and to practice communicating uncertainty using a checklist during role-play patient conversations. METHODS This virtual session was conducted for third-year medical students at the conclusion of their core clerkships. It consisted of prework, didactic lecture, peer role-play, and debriefing. The prework included reflection prompts and an interactive online module. The role-play featured a patient complaining of abdominal pain being discharged from the emergency department without a confirmed diagnosis. Students participated in the role of patient, provider, or observer. RESULTS Data from an anonymous postsession survey (76% response rate; 202 of 265 students) indicated that most students (82%; 152 of 185) felt more comfortable communicating diagnostic uncertainty after the session. A majority (83%; 166 of 201) indicated the session was useful, and most (81%; 149 of 184) indicated it should be included in the curriculum. DISCUSSION This virtual session requires few facilitators; has peer role-play, eliminating the need for standardized patients; and is adaptable for in-person teaching. As its goal was to introduce an approach to communicating diagnostic uncertainty, not achieve mastery, students were not individually assessed for proficiency using the Uncertainty Communication Checklist. Students felt the session intervention was valuable.
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Affiliation(s)
- Maria Poluch
- Medical Student, Sidney Kimmel Medical College at Thomas Jefferson University
| | | | - Nethra Ankam
- Associate Professor, Department of Rehabilitation Medicine, Sidney Kimmel Medical College at Thomas Jefferson University
| | - Jared Kilpatrick
- Medical Education Fellow, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University
| | - Kenzie Cameron
- Research Professor, Division of General Internal Medicine and Geriatrics, Department of Medicine and Department of Medical Education, Northwestern University Feinberg School of Medicine
| | - Shruti Chandra
- Associate Professor, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University
| | - Amanda Doty
- Research Coordinator, Department of Emergency Medicine, Thomas Jefferson University
| | - Matthew Klein
- Assistant Professor, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine
| | - Danielle McCarthy
- Associate Professor, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine
| | - Kristin Rising
- Associate Professor and Director of Acute Care Transitions, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University
| | - David Salzman
- Associate Professor, Department of Emergency Medicine and Department of Medical Education, Northwestern University Feinberg School of Medicine
| | - Deborah Ziring
- Clinical Associate Professor, Department of Medicine, and Senior Associate Dean for Academic Affairs, Sidney Kimmel Medical College at Thomas Jefferson University
| | - Dimitrios Papanagnou
- Professor and Vice Chair for Education, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University; Macy Faculty Scholar, Josiah Macy Jr. Foundation
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O'Neill LB, Bhansali P, Bost JE, Chamberlain JM, Ottolini MC. "Sick or not sick?" A mixed methods study evaluating the rapid determination of illness severity in a pediatric emergency department. Diagnosis (Berl) 2021; 9:207-215. [PMID: 34890171 DOI: 10.1515/dx-2021-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Experienced physicians must rapidly identify ill pediatric patients. We evaluated the ability of an illness rating score (IRS) to predict admission to a pediatric hospital and explored the underlying clinical reasoning of the gestalt assessment of illness. METHODS We used mixed-methods to study pediatric emergency medicine physicians at an academic children's hospital emergency department (ED). Physicians rated patients' illness severity with the IRS, anchored by 0 (totally well) and 10 (critically ill), and shared their rationale with concurrent think-aloud responses. The association between IRS and need for hospitalization, respiratory support, parenteral antibiotics, and resuscitative intravenous (IV) fluids were analyzed with mixed effects linear regression. Area under the curve (AUC) receiver operator characteristic (ROC) curve and test characteristics at different cut-points were calculated for IRS as a predictor of admission. Think-aloud responses were qualitatively analyzed via inductive process. RESULTS A total of 141 IRS were analyzed (mean 3.56, SD 2.30, range 0-9). Mean IRS were significantly higher for patients requiring admission (4.32 vs. 3.13, p<0.001), respiratory support (6.15 vs. 3.98, p = 0.033), IV fluids (4.53 vs. 3.14, p < 0.001), and parenteral antibiotics (4.68 vs. 3.32, p = 0.009). AUC for IRS as a predictor of admission was 0.635 (95% CI: 0.534-0.737). Analysis of 95 think-aloud responses yielded eight categories that describe the underlying clinical reasoning. CONCLUSIONS Rapid assessments as captured by the IRS differentiated pediatric patients who required admission and medical interventions. Think-aloud responses for the rationale for rapid assessments may form the basis for teaching the skill of identifying ill pediatric patients.
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Affiliation(s)
- Laura B O'Neill
- Division of Hospital Medicine at Children's National Hospital, and George Washington University of Medicine and Health Sciences, Washington, DC, USA
| | - Priti Bhansali
- Division of Hospital Medicine at Children's National Hospital, and George Washington University of Medicine and Health Sciences, Washington, DC, USA
| | - James E Bost
- Department of Biostatistics and Study Methodology at Children's National Hospital, and George Washington University of Medicine and Health Sciences, Washington, DC, USA
| | - James M Chamberlain
- Division of Emergency Medicine at Children's National Hospital, and George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Mary C Ottolini
- Tufts University School of Medicine and the George W. Hallett MD Chair of Pediatrics at the Barbara Bush Children's Hospital, Portland, ME, USA
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Battista A, Konopasky A, Durning SJ. The importance of theory and method: A brief reflection on an innovative program of research examining how situational factors influence physicians' clinical reasoning. FASEB Bioadv 2021; 3:490-496. [PMID: 34258518 PMCID: PMC8255829 DOI: 10.1096/fba.2020-00109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 11/26/2022] Open
Abstract
Clinical reasoning, a complex process that involves gathering and synthesizing information to make diagnostic and treatment decisions, is a topic researchers frequently study to mitigate errors. Scientific reasoning has several similarities with clinical reasoning, including the need to generate hypotheses; observe, gather, and interpret evidence; engage in the process of elimination; draw conclusions; and refine and test new hypotheses. However, researchers have only recently begun to take into consideration the role that situational factors (also known as contextual factors), such as language barriers or the lack of diagnostic test results, can play in diagnostic error. Additionally, questions remain about the best ways to teach these complex processes.
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Affiliation(s)
- Alexis Battista
- Henry M Jackson Foundation for the Advancement of Military Medicine Bethesda MD USA
| | - Abigail Konopasky
- Henry M Jackson Foundation for the Advancement of Military Medicine Bethesda MD USA
| | - Steven J Durning
- Uniformed Services University of the Health Sciences Bethesda MD USA
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Konopasky A, Durning SJ, Battista A, Artino AR, Ramani D, Haynes ZA, Woodard C, Torre D. Challenges in mitigating context specificity in clinical reasoning: a report and reflection. ACTA ACUST UNITED AC 2020; 7:291-297. [PMID: 32651977 DOI: 10.1515/dx-2020-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/04/2020] [Indexed: 11/15/2022]
Abstract
Objectives Diagnostic error is a growing concern in U.S. healthcare. There is mounting evidence that errors may not always be due to knowledge gaps, but also to context specificity: a physician seeing two identical patient presentations from a content perspective (e.g., history, labs) yet arriving at two distinct diagnoses. This study used the lens of situated cognition theory - which views clinical reasoning as interconnected with surrounding contextual factors - to design and test an instructional module to mitigate the negative effects of context specificity. We hypothesized that experimental participants would perform better on the outcome measure than those in the control group. Methods This study divided 39 resident and attending physicians into an experimental group receiving an interactive computer training and "think-aloud" exercise and a control group, comparing their clinical reasoning. Clinical reasoning performance in a simulated unstable angina case with contextual factors (i.e., diagnostic suggestion) was determined using performance on a post-encounter form (PEF) as the outcome measure. The participants who received the training and did the reflection were compared to those who did not using descriptive statistics and a multivariate analysis of covariance (MANCOVA). Results Descriptive statistics suggested slightly better performance for the experimental group, but MANCOVA results revealed no statistically significant differences (Pillai's Trace=0.20, F=1.9, df=[4, 29], p=0.15). Conclusions While differences were not statistically significant, this study suggests the potential utility of strategies that provide education and awareness of contextual factors and space for reflective practice.
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Affiliation(s)
- Abigail Konopasky
- Uniformed Services University of the Health Sciences and The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Steven J Durning
- Uniformed Services University of the Health Sciences and The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Alexis Battista
- Uniformed Services University of the Health Sciences and The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Anthony R Artino
- The George Washington University School of Medicine and Health Sciences, Health, Human Function, and Rehabilitation Sciences, Washington, DC, USA
| | - Divya Ramani
- Uniformed Services University of the Health Sciences and The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Zachary A Haynes
- Uniformed Services University of the Health Sciences and The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Catherine Woodard
- Uniformed Services University of the Health Sciences and The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Dario Torre
- Department of Medicine, Uniformed Services University, Bethesda, MD, USA
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Supporting program rigor in newly developed specialty academic programs: Use of a self-evaluation reporting tool for emergency nurse practitioner academic programs. J Am Assoc Nurse Pract 2020; 32:579-582. [DOI: 10.1097/jxx.0000000000000260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Examining the patterns of uncertainty across clinical reasoning tasks: effects of contextual factors on the clinical reasoning process. Diagnosis (Berl) 2020; 7:299-305. [DOI: 10.1515/dx-2020-0019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/20/2020] [Indexed: 11/15/2022]
Abstract
AbstractObjectivesUncertainty is common in clinical reasoning given the dynamic processes required to come to a diagnosis. Though some uncertainty is expected during clinical encounters, it can have detrimental effects on clinical reasoning. Likewise, evidence has established the potentially detrimental effects of the presence of distracting contextual factors (i.e., factors other than case content needed to establish a diagnosis) in a clinical encounter on clinical reasoning. The purpose of this study was to examine how linguistic markers of uncertainty overlap with different clinical reasoning tasks and how distracting contextual factors might affect physicians’ clinical reasoning process.MethodsIn this descriptive exploratory study, physicians participated in a live or video recorded simulated clinical encounter depicting a patient with unstable angina with and without contextual factors. Transcribed think-aloud reflections were coded using Goldszmidt’s clinical reasoning task typology (26 tasks encompassing the domains of framing, diagnosis, management, and reflection) and then those coded categories were examined using linguistic markers of uncertainty (e.g., probably, possibly, etc.).ResultsThirty physicians with varying levels of experience participated. Consistent with expectations, descriptive analysis revealed that physicians expressed more uncertainty in cases with distracting contextual factors compared to those without. Across the four domains of reasoning tasks, physicians expressed the most uncertainty in diagnosis and least in reflection.ConclusionsThese results highlight how linguistic markers of uncertainty can shed light on the role contextual factors might play in uncertainty which can lead to error and why it is essential to find ways of managing it.
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Konopasky A, Durning SJ, Artino AR, Ramani D, Battista A. The Linguistic Effects of Context Specificity: Exploring Affect, Cognitive Processing, and Agency in Physicians' Think-Aloud Reflections. ACTA ACUST UNITED AC 2020; 7:273-280. [PMID: 32304298 DOI: 10.1515/dx-2019-0103] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/09/2020] [Indexed: 11/15/2022]
Abstract
Background The literature suggests that affect, higher-level cognitive processes (e.g. decision-making), and agency (the capacity to produce an effect) are important for reasoning; however, we do not know how these factors respond to context. Using situated cognition theory as a framework, and linguistic tools as a method, we explored the effects of context specificity [a physician seeing two patients with identical presentations (symptoms and findings), but coming to two different diagnoses], hypothesizing more linguistic markers of cognitive load in the presence of contextual factors (e.g. incorrect diagnostic suggestion). Methods In this comparative and exploratory study, 64 physicians each completed one case with contextual factors and one without. Transcribed think-aloud reflections were coded by Linguistic Inquiry and Word Count (LIWC) software for markers of affect, cognitive processes, and first-person pronouns. A repeated-measures multivariate analysis of variance was used to inferentially compare these LIWC categories between cases with and without contextual factors. This was followed by exploratory descriptive analysis of subcategories. Results As hypothesized, participants used more affective and cognitive process markers in cases with contextual factors and more I/me pronouns in cases without. These differences were statistically significant for cognitive processing words but not affective and pronominal words. Exploratory analysis revealed more negative emotions, cognitive processes of insight, and third-person pronouns in cases with contextual factors. Conclusions This study exposes linguistic differences arising from context specificity. These results demonstrate the value of a situated cognition view of patient encounters and reveal the utility of linguistic tools for examining clinical reasoning.
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Affiliation(s)
- Abigail Konopasky
- Assistant Professor of Medicine, The Henry M Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Steven J Durning
- Professor of Medicine and Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Anthony R Artino
- Professor of Health, Human Function and Rehabilitation Sciences, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Divya Ramani
- Research Associate, The Henry M Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Alexis Battista
- Assistant Professor of Medicine, The Henry M Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Konopasky A, Ramani D, Ohmer M, Durning SJ, Artino AR, Battista A. Why health professions education needs functional linguistics: the power of 'stealth words'. MEDICAL EDUCATION 2019; 53:1187-1195. [PMID: 31463980 DOI: 10.1111/medu.13944] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 05/13/2019] [Accepted: 07/04/2019] [Indexed: 06/10/2023]
Abstract
CONTEXT Language is one of the primary modalities for teaching and learning in the health professions in contexts ranging from the more formal teaching relationships of medical school to the guided practice of trainees through continuing education and the deliberate practice of lifelong learning. Yet linguistic analysis, with the possible exception of discourse analysis, has not become a core methodological tool in the field of health professions education (HPE). The purpose of this paper is to argue for the more widespread adoption of one particular approach to linguistics, one that examines less of what learners and instructors say and looks more at how they say it: functional linguistics. FUNCTIONAL LINGUISTICS THE POWER OF 'STEALTH WORDS': This approach theorises and structures the functions of language, regularly focusing attention on 'stealth words' such as I, but and was. Drawing on a rich body of literature in linguistics, psychology, the learning sciences and some early work in HPE, we demonstrate how functional linguistic tools can be applied to better understand learners' and instructors' beliefs, reasoning processes, values and emotions. FUNCTIONAL LINGUISTICS AND REFLECTION AN APPLICATION OF STEALTH WORDS: A brief qualitative analysis of one tool - analysis of the generic use of 'you' to mean 'one' or 'anyone' - demonstrates how functional linguistics can offer insight into physicians' bids for credibility and alignment as they think aloud about their clinical reasoning. FUNCTIONAL LINGUISTICS AND HPE FUTURE DIRECTIONS: Finally, we offer suggestions for how functional linguistic tools might address questions and gaps in four active research areas in HPE: reflection; emotion and reasoning; learning in simulated contexts, and self-regulated learning. CONCLUSIONS We argue that the words used by learners, instructors and practitioners in the health professions as they move through undergraduate and graduate training into practice can offer clues that will help researchers, instructors and colleagues to better support them.
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Affiliation(s)
- Abigail Konopasky
- Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Divya Ramani
- Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Megan Ohmer
- Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Steven J Durning
- Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Anthony R Artino
- Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Alexis Battista
- Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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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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