Clinical Reasoning in the Ward Setting: A Rapid Response Scenario for Residents and Attendings

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.

Therapeutic Reasoning: A Conceptual Challenge for Medical Students' Surgical Clerkship

Issue: Medical students' transition between pre-clinical and clinical environments can be jarring. Unclear expectations, disconnect between the pre-clinical and clinical environments, and feelings of exclusion from the team all negatively influence clerkship experiences. These difficulties are magnified on interventional-based clerkships due to the central role of therapeutic reasoning. Therapeutic reasoning is the process by which clinicians review and select treatments for their patients. Surgical therapeutic reasoning is challenging and infrequently addressed explicitly in the pre-clinical curriculum. This contributes to confusion among medical students as they transition from pre-clinical to clinical learning. Evidence: Multiple studies have identified challenges to medical students' transition to clinical clerkships. Prior authors have outlined numerous barriers to successful medical student integration to clinical teams, including surgical teams. Studies that have assessed students' perceptions of their transition to a clinical setting noted poor understanding of treatment decisions as a source of anxiety. Additionally, of particular importance to medical student team learning is their assimilation into the "communities of clinical practice," groups of healthcare professionals who form teams with which students rotate. Surgeons have distinct approaches to the clinical process compared with non-interventionalists, particularly related to post-diagnostic involvement in care and performing diagnostic workup and treatment concurrently. Knowledge of these approaches is important for integration into surgical teams. Implications: An understanding of interventional therapeutic reasoning is critical to allow for medical students' team integration on surgical and interventional clerkships. By incorporating education involving these concepts during the orientation period prior to students' transition to surgical clerkships, we can help students modify traditional mental frameworks to effectively evaluate, present, and select appropriate interventions for patients. Such education should include a didactic introduction to therapeutic reasoning, interactive discussion with surgeons, and exercises for students to practice skills. This will maximize learning opportunities and clerkship experience.

Exploring procedure-based management reasoning: a case of tension pneumothorax

OBJECTIVES

Management reasoning has not been widely explored but likely requires broader abilities than diagnostic reasoning. An enhanced understanding of management reasoning could improve medical education and patient care. We conducted a novel exploratory study to gain further insights into procedure-based management reasoning.

METHODS

Participant physicians managed a simulated patient who acutely decompensates in a team-based, time-pressured, live scenario. Immediately following the scenario, physicians perform a think-aloud protocol by watching video recordings of their performance and narrating their reflections in real-time. Verbatim transcripts of the think-aloud protocol were inductively coded using a constant comparative method and evaluated for themes.

RESULTS

We recruited 19 physicians (15 internal medicine, one family medicine, and three general surgery) for this study. Recognizing that diagnostic and management reasoning intertwine, this paper focuses on management reasoning's characteristics. We developed three categories of management reasoning factors with eight subthemes. These are Patient factors: Acuity and Preferences; Physician factors: Recognized Errors, Anxiety, Metacognition, Monitoring, and Threshold to Treat; and one Environment factor: Resources.

CONCLUSIONS

Our findings on procedure-based management reasoning are consistent with Situation Awareness and Situated Cognition models and the extant work on management reasoning, demonstrating that management is inherently complex and contextually bound. Unique to this study, all physicians focused on prognosis, indicating that attaining competency in procedural management may require planning and prediction abilities. Physicians also expressed concerns about making mistakes, potentially resulting from the scenario's emphasis on a procedure and our physicians' having less expertise in the treatment of tension pneumothorax.

"Sick or not sick?" A mixed methods study evaluating the rapid determination of illness severity in a pediatric emergency department

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.