Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study

Assessing clinical reasoning skills following a virtual patient dizziness curriculum

OBJECTIVES

Dizziness is a common medical symptom that is frequently misdiagnosed. While virtual patient (VP) education has been shown to improve diagnostic accuracy for dizziness as assessed by VPs, trainee performance has not been assessed on human subjects. The study aimed to assess whether internal medicine (IM) interns after training on a VP-based dizziness curriculum using a deliberate practice framework would demonstrate improved clinical reasoning when assessed in an objective structured clinical examination (OSCE).

METHODS

All available interns volunteered and were randomized 2:1 to intervention (VP education) vs. control (standard clinical teaching) groups. This quasi-experimental study was conducted at one academic medical center from January to May 2021. Both groups completed pre-posttest VP case assessments (scored as correct diagnosis across six VP cases) and participated in an OSCE done 6 weeks later. The OSCEs were recorded and assessed using a rubric that was systematically developed and validated.

RESULTS

Out of 21 available interns, 20 participated. Between intervention (n=13) and control (n=7), mean pretest VP diagnostic accuracy scores did not differ; the posttest VP scores improved for the intervention group (3.5 [SD 1.3] vs. 1.6 [SD 0.8], p=0.007). On the OSCE, the means scores were higher in the intervention (n=11) compared to control group (n=4) for physical exam (8.4 [SD 4.6] vs. 3.9 [SD 4.0], p=0.003) and total rubric score (43.4 [SD 12.2] vs. 32.6 [SD 11.3], p=0.04).

CONCLUSIONS

The VP-based dizziness curriculum resulted in improved diagnostic accuracy among IM interns with enhanced physical exam skills retained at 6 weeks post-intervention.

Multiple sclerosis diagnosis: Knowledge gaps and opportunities for educational intervention in neurologists in the United States

Background:

Few studies have addressed the results of educational efforts concerning proper use of McDonald criteria (MC) revisions outside multiple sclerosis (MS) subspecialty centers. Neurology residents and MS subspecialist neurologists demonstrated knowledge gaps for core elements of the MC in a recent prior study.

Objective:

To assess comprehension and application of MC core elements by non-MS specialist neurologists in the United States who routinely diagnose MS.

Methods:

Through a cross-sectional study design, a previously developed survey instrument was distributed online.

Results:

A total of 222 neurologists completed the study survey. Syndromes atypical for MS were frequently incorrectly considered “typical” MS presentations. Fourteen percent correctly identified definitions of both “periventricular” and “juxtacortical” lesions and 2% correctly applied these terms to 9/9 images. Twenty-four percent correctly identified all four central nervous system (CNS) regions for satisfaction of magnetic resonance imaging (MRI) dissemination in space. In two presented cases, 61% and 71% correctly identified dissemination in time (DIT) was not fulfilled, and 85% and 86% subsequently accepted nonspecific historical symptoms without objective evidence for DIT fulfillment.

Conclusion:

The high rate of knowledge deficiencies and application errors of core elements of the MC demonstrated by participants in this study raise pressing questions concerning adequacy of dissemination and educational efforts upon publication of revisions to MC.

Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods

OBJECTIVES

Isolated dizziness is a challenging stroke presentation in the emergency department, but little is known about this problem in other clinical settings. We sought to compare stroke hospitalizations after treat-and-release clinic visits for purportedly "benign dizziness" between general and specialty care settings.

METHODS

This was a population-based retrospective cohort study from a national database. We included clinic patients with a first incident treat-and-release visit diagnosis of non-specific dizziness/vertigo or a peripheral vestibular disorder (ICD-9-CM 780.4 or 386.x [not 386.2]). We compared general care (internal medicine, family medicine) vs. specialty care (neurology, otolaryngology) providers. We used propensity scores to control for baseline stroke risk differences unrelated to dizziness diagnosis. We measured excess (observed>expected) stroke hospitalizations in the first 30 d (i.e., missed strokes associated with an adverse event).

RESULTS

We analyzed 144,355 patients discharged with "benign dizziness" (n=117,117 diagnosed in general care; n=27,238 in specialty care). After propensity score matching, patients in both groups were at higher risk of stroke in the first 30 d (rate difference per 10,000 treat-and-release visits for "benign dizziness" 24.9 [95% CI 18.6-31.2] in general care and 10.6 [95% CI 6.3-14.9] in specialty care). Short-term stroke risk was higher in general care than specialty care (relative risk, RR 2.2, 95% CI 1.5-3.2) while the long-term risk was not significantly different (RR 1.3, 95% CI 0.9-1.9), indicating higher misdiagnosis-related harms among dizzy patients who initially presented to generalists after adequate propensity matching.

CONCLUSIONS

Missed stroke-related harms in general care were roughly twice that in specialty care. Solutions are needed to address this care gap.