Eliciting and displaying diagnostic reasoning during educational rounds in internal medicine: who learns from whom?

Management of residents in difficulty in a Swiss general internal medicine outpatient clinic: Change is necessary!

AIMS OF THE STUDY

Residents in difficulty are a major cause for concern in medical education, with a prevalence of 7-15%. They are often detected late in their training and cannot make use of remediation plans. Nowadays, most training hospitals in Switzerland do not have a specific program to identify and manage residents in difficulty. The aim of the study was to explore the challenges perceived by physicians regarding the process of identifying, diagnosing, and supporting residents in difficulty in a structured and programmatic way. We explored perceptions of physicians at different hierarchical levels (residents (R), Chief residents (CR), attending physicians (A), Chief Physician (CP)) in order to better understand these challenges.

METHODS

We conducted an exploratory qualitative study between December 2015 and July 2016. We asked volunteers from the Primary Care Division of the Geneva University Hospitals to partake to three focus groups (with CR, A, R) and one interview with the division's CP. We transcribed, coded, and qualitatively analyzed the three focus groups and the interview, using a content thematic approach and Fishbein's conceptual framework.

RESULTS

We identified similarities and differences in the challenges of the management of residents in difficulty on a programmatic way amongst physicians of different hierarchical levels. Our main findings: Supervisors (CR, A, CP) have good identification skills of residents in difficulty, but they did not put in place systematic remediation strategies.Supervisors (CR, A) were concerned about managing residents in difficulty. They were aware of the possible adverse effects on patient care, but "feared to harm" resident's career by documenting a poor institutional assessment.Residents "feared to share" their own difficulties with their supervisors. They thought that it would impact their career negatively.The four physician's hierarchical level reported environmental constraints (lack of funding, time constraint, lack of time and resources…).

CONCLUSION

Our results add two perspectives to specialized recommendations regarding the implementation of remediation programs for residents in difficulty. The first revolves around the need to identify and fully understand not only the beliefs but also the implicit norms and the feeling of self-efficacy that are shared by teachers and that are likely to motivate them to engage in the management of residents in difficulty. The second emphasizes the importance of analyzing these elements that constitute the context for a change and of identifying, in close contact with the heads of the institutions, which factors may favor or hinder it. This research action process has fostered awareness and discussions at different levels. Since then, various actions and processes have been put in place at the Faculty of Medicine in Geneva.

Justify Your Answer: The Role of Written Think Aloud in Script Concordance Testing

Construct: Clinical reasoning assessment is a growing area of interest in the medical education literature. Script concordance testing (SCT) evaluates clinical reasoning in conditions of uncertainty and has emerged as an innovative tool in the domain of clinical reasoning assessment. SCT quantifies the degree of concordance between a learner and an experienced clinician and attempts to capture the breadth of responses of expert clinicians, acknowledging the significant yet acceptable variation in practice under situations of uncertainty.

BACKGROUND

SCT has been shown to be a valid and reliable clinical reasoning assessment tool. However, as SCT provides only quantitative information, it may not provide a complete assessment of clinical reasoning.

APPROACH

Think aloud (TA) is a qualitative research tool used in clinical reasoning assessment in which learners verbalize their thought process around an assigned task. This study explores the use of TA, in the form of written reflection, in SCT to assess resident clinical reasoning, hypothesizing that the information obtained from the written TA would enrich the quantitative data obtained through SCT. Ninety-one pediatric postgraduate trainees and 21 pediatricians from 4 Canadian training centers completed an online test consisting of 24 SCT cases immediately followed by retrospective written TA. Six of 24 cases were selected to gather TA data. These cases were chosen to allow all phases of clinical decision making (diagnosis, investigation, and treatment) to be represented in the TA data. Inductive thematic analysis was employed when systematically reviewing TA responses.

RESULTS

Three main benefits of adding written TA to SCT were identified: (a) uncovering instances of incorrect clinical reasoning despite a correct SCT response, (b) revealing sound clinical reasoning in the context of a suboptimal SCT response, and (c) detecting question misinterpretation.

CONCLUSIONS

Written TA can optimize SCT by demonstrating when correct examinee responses are based on guessing or uncertainty rather than robust clinical rationale. TA can also enhance SCT by allowing examinees to provide justification for responses that otherwise would have been considered incorrect and by identifying questions that are frequently misinterpreted to avoid including them in future examinations. TA also has significant value in differentiating between acceptable variations in expert clinician responses and deviance associated with faulty rationale or question misinterpretation; this could improve SCT reliability. A written TA protocol appears to be a valuable tool to assess trainees' clinical reasoning and can strengthen the quantitative assessment provided by SCT.

THE APPLICATION OF IMPROVED, STRUCTURED AND INTERACTIVE GROUP LEARNING METHODS IN DIAGNOSTIC RADIOLOGY

This study provides an example on how it is possible to design environments in a diagnostic radiology department that could meet learning demands implied by the introduction of new imaging technologies. The innovative aspect of the design does not result from the implementation of any specific tool for learning. Instead, advancement is achieved by a novel set-up of existing technologies and an interactive format that allows for focussed discussions between learners with different levels of expertise. Consequently, the study points to what is seen as the underexplored possibilities of tailoring basic and specialist training that meet the new demands given by leading-edge technologies.

Teaching in the ICU

Teaching in the fast-paced, high-pressure environment of the ICU can be very demanding. Thus, the educator-intensivist must learn teaching strategies that are time-efficient, simple, and successful. In this article, we provide an overview of the current and relevant teaching theories and highlight potential obstacles and limitations to teaching in the ICU. In the second part, we discuss a sample of simple approaches to optimize the ICU-rotation curriculum as well as effective techniques to improve teaching, while not compromising quality of care.

Benefits of knowledge-based interprofessional communication skills training in medical undergraduate education

OBJECTIVES

Good interprofessional communication is fundamental to effective teamworking in medicine. Finalmed is a private course that teaches the principles and methods of clinical presenting as an iterative technique of reasoning though clinical data. We have tested the efficacy of this technique using a questionnaire-based study.

DESIGN

An anonymized 10-point Likert scale questionnaire was designed.

SETTING

Questionnaires were distributed at five UK courses and two UAE courses.

PARTICIPANTS

Questionnaires were given to all students attending these courses.

MAIN OUTCOME MEASURES

The questionnaire included pre- and post-course questions addressing self-reported confidence in clinical presenting (CCP) and effectiveness in clinical presenting (ECP). We also asked whether attendees felt that clinical presenting should be integrated formally into medical school curricula.

RESULTS

A total of 331/395 questionnaires were returned. Median improvement in CCP was 50% (P < 0.0001) and in ECP was 40% (P < 0.0001), irrespective of country of study, graduate entry status and whether the student felt that they had been exposed to these techniques previously. Students recorded a strong opinion in favour of integrating the content and style of the Finalmed course into their medical school curriculum, with 286 students (86%) recording a score of ≥8.

CONCLUSION

Our study suggests that after a two- or three-day dedicated course, both self-reported confidence and effectiveness in clinical presenting significantly improve. Furthermore, students in the UK and the UAE returned a desire for integration into medical school curricula of IPC through the teaching of clinical presenting.

When the evaluated becomes evaluator: what can we learn from students' experiences during clerkships?

PURPOSE

To identify aspects that influence students' evaluation of the overall quality of clerkships and learning in clinical settings.

METHOD

The authors analyzed 2,450 questionnaires dated 1997 through 2005 that evaluated clerkships of seven medical specialties (internal medicine, surgery, pediatrics, psychiatry, community medicine, emergency medicine, and obstetrics-gynecology). Students rated 22 questionnaire items addressing clerkships' global evaluation and domains related to structure, supervision, and clinical and problem-solving learning (PSL) activities using a five-point Likert scale. The authors performed statistical analysis using principal component analysis and regression analysis of items associated with students' global evaluation of clerkships.

RESULTS

Correlation between clerkships' global ratings and ratings derived from the evaluation questionnaire was 0.871 (P < .0001). Clerkships' quality was mainly related to their organization, students' integration into clerkship, improvement of clinical skills, supervision, and residents' availability (r = 0.405; P < .0001). Among learning activities, opportunities for clinical practice predominated as the contributing factor to the overall perceived quality of most clerkships, but less than PSL activities in psychiatry (r = 0.070 versus 0.261, respectively; P < .001) and community medicine (r = 0.126 versus 0.298, respectively; P < .001); in surgery, both clinical practice and PSL activities contributed minimally to the clerkships' perceived quality (r = 0.150 and 0.148, respectively; P > .05).

CONCLUSIONS

Factors influencing students' evaluation of a clerkship vary among medical specialties and depend not only on the teaching and teacher but also on the clerkship's organization, supervision, and learning activities. For clerkships where direct and multiple access to patients is more difficult, written case-based PSL activities proved complementary to direct patient encounter activities.

Improving oral presentation skills with a clinical reasoning curriculum: a prospective controlled study

PURPOSE

The oral case presentation is an essential part of clinical medicine, but teaching medical students to present clinical data remains difficult. Presentation skills depend on the ability to obtain, process, and organize patient data. Clinical reasoning is fundamental to the development of these skills. We compared a clinical reasoning curriculum with standard ward instruction for improving presentation skills and clinical performance.

SUBJECTS AND METHODS

Between October 1998 and May 1999, 62 third-year medical students at three hospitals were assigned to a 4-week clinical reasoning curriculum (n = 27) or a control group (n = 35) that underwent routine instruction. The curriculum consisted of four 1-hour group sessions and 1 hour of individual videotaped instruction, and taught students to use the principles of clinical reasoning, such as generation and refinement of diagnostic hypothesis, interpretation of diagnostic tests, and causal reasoning, to determine data for inclusion in the oral presentation. We videotaped students presenting two standardized case histories; one at baseline and a second 4 weeks later. Two independent evaluators who were blinded to the group assignments reviewed the videotapes and scored them for presentation quality and efficiency, and general speaking ability.

RESULTS

Mean (+/- SD) presentation times at baseline were similar in the two groups (intervention group: 8 +/- 2 minutes; control group: 8 +/- 2 minutes; P = 0.74). Presentation time in students who were taught clinical reasoning decreased by 3 +/- 2 minutes, but increased by 2 +/- 2 minutes in control students. The difference in the changes between the groups was statistically significant (mean difference = 4 minutes; 95% confidence interval [CI]: 3 to 5 minutes; P <0.001). Presentation quality scores at baseline were similar in both groups (intervention group: 17 +/- 8 points; control group: 20 +/- 7 points; P = 0.11). Students who were taught the clinical reasoning curriculum had an improvement of 9 +/- 6 points in the quality of their presentations, while control students had an improvement of 2 +/- 7 points (on a scale of 4-36). The difference in the changes between the groups was statistically significant (mean difference = 4 points; 95% CI: 1 to 7 points; P = 0.04).

CONCLUSION

A clinical reasoning curriculum, in combination with video-based individual instruction, improves the efficiency and quality of oral presentations, and may augment clinical performance.