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Elster MJ, Parsons AS, Collins S, Gusic ME, Hauer KE. 'We're like Spider-Man; with great power comes great responsibility': Coaches' experiences supporting struggling medical students. Med Teach 2024:1-9. [PMID: 38588710 DOI: 10.1080/0142159x.2024.2337250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/26/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Medical students can experience a range of academic and non-academic struggles. Coaching is a valuable strategy to support learners, but coaches describe working with struggling learners as taxing. Transformative learning theory (TLT) provides insights into how educators grow from challenging experiences to build resilience. This study explores how coaches evolve as educators through supporting struggling students. METHODS This qualitative study grounded in an interpretivist paradigm used interviews of longitudinal medical student coaches at two academic institutions. Interviews, using TLT as a sensitizing concept, explored coaches' experience coaching struggling learners. We performed thematic analysis. RESULTS We interviewed 15 coaches. Coaches described supporting students through multi-faceted struggles which often surprised the coach. Three themes characterized coaches' experiences: personal responsibility, emotional response, and personal learning. Coaches shouldered high personal responsibility for learners' success. For some, this burden felt emotional, raised parental instincts and questions about maintaining boundaries with learners. Coaches evolved their coaching approach, challenged biases, and built skills. Coaches learned to better appreciate the learner point of view and employ resources to support students. DISCUSSION Through navigating learner struggles, educators can gain self-efficacy, learn to understand learners' perspectives, and evolve their coaching approach to lessen their personal emotional burden through time.
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Affiliation(s)
- Martha J Elster
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Andrew S Parsons
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Sally Collins
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | | | - Karen E Hauer
- University of California San Francisco School of Medicine, San Francisco, California, USA
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Goh E, Gallo R, Hom J, Strong E, Weng Y, Kerman H, Cool J, Kanjee Z, Parsons AS, Ahuja N, Horvitz E, Yang D, Milstein A, Olson APJ, Rodman A, Chen JH. Influence of a Large Language Model on Diagnostic Reasoning: A Randomized Clinical Vignette Study. medRxiv 2024:2024.03.12.24303785. [PMID: 38559045 PMCID: PMC10980135 DOI: 10.1101/2024.03.12.24303785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Importance Diagnostic errors are common and cause significant morbidity. Large language models (LLMs) have shown promise in their performance on both multiple-choice and open-ended medical reasoning examinations, but it remains unknown whether the use of such tools improves diagnostic reasoning. Objective To assess the impact of the GPT-4 LLM on physicians' diagnostic reasoning compared to conventional resources. Design Multi-center, randomized clinical vignette study. Setting The study was conducted using remote video conferencing with physicians across the country and in-person participation across multiple academic medical institutions. Participants Resident and attending physicians with training in family medicine, internal medicine, or emergency medicine. Interventions Participants were randomized to access GPT-4 in addition to conventional diagnostic resources or to just conventional resources. They were allocated 60 minutes to review up to six clinical vignettes adapted from established diagnostic reasoning exams. Main Outcomes and Measures The primary outcome was diagnostic performance based on differential diagnosis accuracy, appropriateness of supporting and opposing factors, and next diagnostic evaluation steps. Secondary outcomes included time spent per case and final diagnosis. Results 50 physicians (26 attendings, 24 residents) participated, with an average of 5.2 cases completed per participant. The median diagnostic reasoning score per case was 76.3 percent (IQR 65.8 to 86.8) for the GPT-4 group and 73.7 percent (IQR 63.2 to 84.2) for the conventional resources group, with an adjusted difference of 1.6 percentage points (95% CI -4.4 to 7.6; p=0.60). The median time spent on cases for the GPT-4 group was 519 seconds (IQR 371 to 668 seconds), compared to 565 seconds (IQR 456 to 788 seconds) for the conventional resources group, with a time difference of -82 seconds (95% CI -195 to 31; p=0.20). GPT-4 alone scored 15.5 percentage points (95% CI 1.5 to 29, p=0.03) higher than the conventional resources group. Conclusions and Relevance In a clinical vignette-based study, the availability of GPT-4 to physicians as a diagnostic aid did not significantly improve clinical reasoning compared to conventional resources, although it may improve components of clinical reasoning such as efficiency. GPT-4 alone demonstrated higher performance than both physician groups, suggesting opportunities for further improvement in physician-AI collaboration in clinical practice.
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Affiliation(s)
- Ethan Goh
- Stanford Center for Biomedical Informatics Research, Stanford University, Stanford, CA
- Stanford Clinical Excellence Research Center, Stanford University, Stanford, CA
| | - Robert Gallo
- Center for Innovation to Implementation, VA Palo Alto Health Care System, PA, CA
| | - Jason Hom
- Stanford University School of Medicine, Stanford, CA
| | - Eric Strong
- Stanford University School of Medicine, Stanford, CA
| | - Yingjie Weng
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA
| | - Hannah Kerman
- Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Josephine Cool
- Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Zahir Kanjee
- Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Neera Ahuja
- Stanford University School of Medicine, Stanford, CA
| | - Eric Horvitz
- Microsoft, Redmond, WA
- Stanford HAI, Stanford, CA
| | | | - Arnold Milstein
- Stanford Clinical Excellence Research Center, Stanford University, Stanford, CA
| | | | - Adam Rodman
- Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Stanford University, Stanford, CA
- Stanford Clinical Excellence Research Center, Stanford University, Stanford, CA
- Division of Hospital Medicine, Stanford University, Stanford, CA
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Phadke SV, Dalal C, Seetharaman R, Parsons AS. Lessons in clinical reasoning - pitfalls, myths, and pearls: a case of tarsal tunnel syndrome caused by an intraneural ganglion cyst. Diagnosis (Berl) 2024; 0:dx-2023-0161. [PMID: 38401131 DOI: 10.1515/dx-2023-0161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 01/15/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVES Intraneural ganglionic cysts are non-neoplastic cysts that can cause signs and symptoms of peripheral neuropathy. However, the scarcity of such cases can lead to cognitive biases. Early surgical exploration of space occupying lesions plays an important role in identification and improving the outcomes for intraneural ganglionic cysts. CASE PRESENTATION This patient presented with loss of sensation on the right sole with tingling numbness for six months. A diagnosis of tarsal tunnel syndrome was made. Nerve conduction study revealed that the mixed nerve action potential (NAP) was absent in the right medial and lateral plantar nerves. The magnetic resonance imaging (MRI) found a cystic lesion measuring 1.4×1.8×3.8 cm as the presumed cause of the neuropathy. Surgical exploration revealed a ganglionic cyst traversing towards the flexor retinaculum with baby cysts. The latter finding came as a surprise to the treating surgeon and was confirmed to be an intraneural ganglionic cyst based on the histopathology report. CONCLUSIONS Through integrated commentary by a case discussant and reflection by an orthopedician, this case highlights the significance of the availability heuristic, confirmation bias, and anchoring bias in a case of rare disease. Despite diagnostic delays, a medically knowledgeable patient's involvement in their own care lead to a more positive outcome. A fish-bone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic delay. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl related to availability heuristic and the sunk cost fallacy.
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Affiliation(s)
- Sanjay Vishnu Phadke
- Visiting Orthopaedic Surgeon, 29491 Indian Institute of Technology , Mumbai, India
| | - Chirag Dalal
- Visiting Orthopaedic Surgeon, Madhu Polyclinic and Nursing Home, 29491 Indian Institute of Technology , Mumbai, India
| | - Rajmohan Seetharaman
- Department of Pharmacology & Therapeutics, 29549 Seth GS Medical College & KEM Hospital , Mumbai, India
| | - Andrew S Parsons
- Department of Medicine and Public Health, 12349 University of Virginia School of Medicine , Charlottesville, VA, USA
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Young G, Meyer J, Crane I, Martindale JR, Bray MJ, Ryan MS, Parsons AS. A Longitudinal, Structured Clinical Remediation Program for Medical Students. Acad Med 2023; 98:S191. [PMID: 37983436 DOI: 10.1097/acm.0000000000005401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Affiliation(s)
- Gregory Young
- Author affiliations: G. Young, J. Meyer, I. Crane, J.R. Martindale, M.J. Bray, M.S. Ryan, A.S. Parsons, University of Virginia
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Parsons AS, Greenfield J, Bradley E, Waggoner-Fountain LA, Norwood V, Weis A, Kulkarni S, Bray MJ, Keeley M, Ryan MS. Summative Entrustment Decisions in UME: Outcomes of a Binding Entrustment Committee Decision. Acad Med 2023; 98:S186-S187. [PMID: 37983431 DOI: 10.1097/acm.0000000000005391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Affiliation(s)
- Andrew S Parsons
- Author affiliations: A.S. Parsons, J. Greenfield, E. Bradley, L.A. Waggoner-Fountain, V. Norwood, A. Weis, S. Kulkarni, M.J. Bray, M. Keeley, M.S. Ryan, University of Virginia School of Medicine
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Boyle SM, Martindale J, Parsons AS, Sozio SM, Hilburg R, Bahrainwala J, Chan L, Stern LD, Warburton KM. Development and Validation of a Formative Assessment Tool for Nephrology Fellows' Clinical Reasoning. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00267. [PMID: 37851423 PMCID: PMC10843222 DOI: 10.2215/cjn.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Diagnostic errors are commonly driven by failures in clinical reasoning. Deficits in clinical reasoning are common among graduate medical learners, including nephrology fellows. We created and validated an instrument to assess clinical reasoning in a national cohort of nephrology fellows and established performance thresholds for remedial coaching. METHODS Experts in nephrology education and clinical reasoning remediation designed an instrument to measure clinical reasoning through a written patient encounter note from a web-based, simulated AKI consult. The instrument measured clinical reasoning in three domains: problem representation, differential diagnosis with justification, and diagnostic plan with justification. Inter-rater reliability was established in a pilot cohort ( n =7 raters) of first-year nephrology fellows using a two-way random effects agreement intraclass correlation coefficient model. The instrument was then administered to a larger cohort of first-year fellows to establish performance standards for coaching using the Hofstee method ( n =6 raters). RESULTS In the pilot cohort, there were 15 fellows from four training program, and in the study cohort, there were 61 fellows from 20 training programs. The intraclass correlation coefficients for problem representation, differential diagnosis, and diagnostic plan were 0.90, 0.70, and 0.50, respectively. Passing thresholds (% total points) in problem representation, differential diagnosis, and diagnostic plan were 59%, 57%, and 62%, respectively. Fifty-nine percent ( n =36) met the threshold for remedial coaching in at least one domain. CONCLUSIONS We provide validity evidence for a simulated AKI consult for formative assessment of clinical reasoning in nephrology fellows. Most fellows met criteria for coaching in at least one of three reasoning domains, demonstrating a need for learner assessment and instruction in clinical reasoning.
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Affiliation(s)
- Suzanne M. Boyle
- Section of Nephrology, Hypertension, and Kidney Transplantation, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - James Martindale
- Office of Medical Education, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Andrew S. Parsons
- Division of General, Geriatric, Palliative, and Hospital Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Stephen M. Sozio
- Division of Nephrology, Department of Medicine, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel Hilburg
- Renal, Electrolyte, and Hypertension Division, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jehan Bahrainwala
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Lili Chan
- Barbara T. Murphy Division of Nephrology, Mt. Sinai School of Medicine, New York, New York
| | - Lauren D. Stern
- Renal Section, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Karen M. Warburton
- Division of Nephrology, University of Virginia School of Medicine, Charlottsville, Virginia
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Klein S, Eaton KP, Bodnar BE, Keller SC, Helgerson P, Parsons AS. Transforming Health Care from Volume to Value: Leveraging Care Coordination Across the Continuum. Am J Med 2023; 136:985-990. [PMID: 37481020 DOI: 10.1016/j.amjmed.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Sharon Klein
- Department of Medicine, New York University Langone Health, New York
| | - Kevin P Eaton
- Department of Medicine, New York University Langone Health, Brooklyn
| | - Benjamin E Bodnar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Sara C Keller
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Paul Helgerson
- Department of Medicine, University of Virginia School of Medicine, Charlottesville
| | - Andrew S Parsons
- Department of Medicine, University of Virginia School of Medicine, Charlottesville.
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Trumbull DA, Braschi EL, Jain A, Southwick FS, Parsons AS, Radhakrishnan NS. Lessons in clinical reasoning - pitfalls, myths, and pearls: a case of crushing, substernal chest pain. Diagnosis (Berl) 2023; 10:316-321. [PMID: 37441731 DOI: 10.1515/dx-2022-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/25/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES Diagnostic error is not uncommon and diagnostic accuracy can be improved with the use of problem representation, pre-test probability, and Bayesian analysis for improved clinical reasoning. CASE PRESENTATION A 48-year-old female presented as a transfer from another Emergency Department (ED) to our ED with crushing, substernal pain associated with dyspnea, diaphoresis, nausea, and a tingling sensation down both arms with radiation to the back and neck. Troponins were elevated along with an abnormal electrocardiogram. A negative myocardial perfusion scan led to the patient's discharge. The patient presented to the ED 10 days later with an anterior ST-elevation myocardial infarction. CONCLUSIONS An overemphasis on a single testing modality led to diagnostic error and a severe event. The use of pre-test probabilities guided by history-taking can lead to improved interpretation of test results, ultimately improving diagnostic accuracy and preventing serious medical errors.
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Affiliation(s)
| | - Erica L Braschi
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Ankur Jain
- Baptist Heart Specialists, Jacksonville, FL, USA
| | | | - Andrew S Parsons
- Section of Hospital Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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Dreicer JJ, Parsons AS, Joudi T, Stern S, Olson APJ, Rencic JJ. Framework and Schema are False Synonyms: Defining Terms to Improve Learning. Perspect Med Educ 2023; 12:294-303. [PMID: 37520506 PMCID: PMC10377745 DOI: 10.5334/pme.947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023]
Abstract
Clinical reasoning is an essential expertise of health care professionals that includes the complex cognitive processes that lead to diagnosis and management decisions. In order to optimally teach, learn, and assess clinical reasoning, it is imperative for teachers and learners to have a shared understanding of the language. Currently, educators use the terms schema and framework interchangeably but they are distinct concepts. In this paper, we offer definitions for schema and framework and use the high-stakes field of aviation to demonstrate the interplay of these concepts. We offer examples of framework and schema in the medical education field and discuss how a clear understanding of these concepts allows for greater intentionality when teaching and assessing clinical reasoning.
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Affiliation(s)
- Jessica J. Dreicer
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, US
| | - Andrew S. Parsons
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, US
| | - Tony Joudi
- Fourth-year medical student at the Boston University Chobanian and Avedisian School of Medicine, US
| | - Scott Stern
- University of Chicago, Chicago, Illinois, US
| | - Andrew P. J. Olson
- Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, US
| | - Joseph J. Rencic
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, US
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Niranjan-Azadi A, Moulder G, Gusic ME, Hoke G, Pahwa A, Parsons AS. A novel virtual course to teach medical students high-value decision-making. Clin Teach 2023:e13597. [PMID: 37415282 DOI: 10.1111/tct.13597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/05/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Although a clinician's ability to employ high-value decision-making is influenced by training, many undergraduate medical education programmes lack a formal curriculum in high-value, cost-conscious care. We present a curriculum developed through a cross-institutional collaboration that was used to teach students at two institutions about this topic and can serve as a framework for other institutions to develop similar curricula. APPROACH The faculty from the University of Virginia and the Johns Hopkins University School of Medicine created a 2-week-long online course to teach medical students the fundamentals of high-value care. The course consisted of learning modules, clinical cases, textbook studies, journal clubs and a competitive 'Shark Tank' final project where students proposed a realistic intervention to promote high-value clinical care. EVALUATION Over two-thirds of students rated the course's quality as excellent or very good. Most found the online modules (92%), assigned textbook readings (89%) and 'Shark Tank' competition (83%) useful. To evaluate the student's ability to apply the concepts learned during the course in clinical contexts, we developed a scoring rubric based on the New World Kirkpatrick Model to evaluate students' proposals. Groups chosen as finalists (as determined by faculty judges) were more likely to be fourth-year students (56%), achieved higher overall scores (p = 0.03), better incorporated cost impact at several levels (patient, hospital and national) (p = 0.001) and discussed both positive and negative impacts on patient safety (p = 0.04). IMPLICATIONS This course provides a framework for medical schools to use in their teaching of high-value care. Cross-institutional collaboration and online content overcame local barriers such as contextual factors and lack of faculty expertise, allowed for greater flexibility, and enabled focused curricular time to be spent on a capstone project competition. Prior clinical experience amongst medical students may be an enabling factor in promoting application of learning related to high-value care.
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Affiliation(s)
- Ashwini Niranjan-Azadi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Glenn Moulder
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Maryellen E Gusic
- Senior Associate Dean for Education and Professor of Biomedical Education and Data Science, Lewis Katz School of Medicine at Temple University, Pennsylvania, USA
| | - George Hoke
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Amit Pahwa
- Department of Medicine and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew S Parsons
- Department of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Abdoler EA, Parsons AS, Wijesekera TP. The future of teaching management reasoning: important questions and potential solutions. Diagnosis (Berl) 2023; 10:19-23. [PMID: 36420532 DOI: 10.1515/dx-2022-0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022]
Abstract
Management reasoning is distinct from but inextricably linked to diagnostic reasoning in the iterative process that is clinical reasoning. Complex and situated, management reasoning skills are distinct from diagnostic reasoning skills and must be developed in order to promote cogent clinical decisions. While there is growing interest in teaching management reasoning, key educational questions remain regarding when it should be taught, how it can best be taught in the clinical setting, and how it can be taught in a way that helps mitigate implicit bias. Here, we describe several useful tools to structure teaching of management reasoning across learner levels and educational settings. The management script provides a scaffold for organizing knowledge around management and can serve as a springboard for discussion of uncertainty, thresholds, high-value care, and shared decision-making. The management pause reserves space for management discussions and exploration of a learner's reasoning. Finally, the equity reflection invites learners to examine management decisions from a health equity perspective, promoting the practice of metacognition around implicit bias. These tools are easily deployable, and - when used regularly - foster a learning environment primed for the successful teaching of management reasoning.
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Affiliation(s)
- Emily A Abdoler
- Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Andrew S Parsons
- Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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Schaye V, Parsons AS, Graber ML, Olson APJ. The future of diagnosis - where are we going? Diagnosis (Berl) 2023; 10:1-3. [PMID: 36720463 DOI: 10.1515/dx-2023-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Verity Schaye
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Andrew S Parsons
- Department of Medicine, Section of Hospital Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Mark L Graber
- Founder and President Emeritus, Society to Improve Diagnosis in Medicine, Plymouth, MA, USA.,Professor Emeritus, Stony Brook University, NY, USA
| | - Andrew P J Olson
- Division of Hospital Medicine, Department of Medicine, Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
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Affiliation(s)
- Thilan P Wijesekera
- assistant professor, Department of Internal Medicine, Yale University School of Medicine
| | - Andrew S Parsons
- assistant professor, Department of Medicine, University of Virginia School of Medicine
| | - Emily A Abdoler
- assistant professor, Department of Medicine, University of Michigan
| | - Robert L Trowbridge
- associate professor, Department of Medicine, Tufts University School of Medicine and Maine Medical Center
| | - Steven J Durning
- professor, Department of Medicine, Uniformed Services University of the Health Sciences
| | - Joseph J Rencic
- professor, Department of Medicine, Boston University School of Medicine
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Peterson BD, Magee CD, Martindale JR, Dreicer JJ, Mutter MK, Young G, Sacco MJ, Parsons LC, Collins SR, Warburton KM, Parsons AS. REACT: Rapid Evaluation Assessment of Clinical Reasoning Tool. J Gen Intern Med 2022; 37:2224-2229. [PMID: 35710662 PMCID: PMC9202973 DOI: 10.1007/s11606-022-07513-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 03/25/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Clinical reasoning encompasses the process of data collection, synthesis, and interpretation to generate a working diagnosis and make management decisions. Situated cognition theory suggests that knowledge is relative to contextual factors, and clinical reasoning in urgent situations is framed by pressure of consequential, time-sensitive decision-making for diagnosis and management. These unique aspects of urgent clinical care may limit the effectiveness of traditional tools to assess, teach, and remediate clinical reasoning. METHODS Using two validated frameworks, a multidisciplinary group of clinicians trained to remediate clinical reasoning and with experience in urgent clinical care encounters designed the novel Rapid Evaluation Assessment of Clinical Reasoning Tool (REACT). REACT is a behaviorally anchored assessment tool scoring five domains used to provide formative feedback to learners evaluating patients during urgent clinical situations. A pilot study was performed to assess fourth-year medical students during simulated urgent clinical scenarios. Learners were scored using REACT by a separate, multidisciplinary group of clinician educators with no additional training in the clinical reasoning process. REACT scores were analyzed for internal consistency across raters and observations. RESULTS Overall internal consistency for the 41 patient simulations as measured by Cronbach's alpha was 0.86. A weighted kappa statistic was used to assess the overall score inter-rater reliability. Moderate reliability was observed at 0.56. DISCUSSION To our knowledge, REACT is the first tool designed specifically for formative assessment of a learner's clinical reasoning performance during simulated urgent clinical situations. With evidence of reliability and content validity, this tool guides feedback to learners during high-risk urgent clinical scenarios, with the goal of reducing diagnostic and management errors to limit patient harm.
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Affiliation(s)
| | - Charles D Magee
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | | | - M Kathryn Mutter
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Gregory Young
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Laura C Parsons
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | | | - Andrew S Parsons
- University of Virginia School of Medicine, Charlottesville, VA, USA.
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15
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Dreicer JJ, Parsons AS, Rencic J. The Diagnostic Medical Interview. Med Clin North Am 2022; 106:601-614. [PMID: 35725227 DOI: 10.1016/j.mcna.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The diagnostic medical interview spans from the chief concern to the formation of a differential diagnosis. The patient's unique expression of their symptoms is the central component of this conversation. The interview should begin by eliciting the patient's chief concern with an open-ended question and then move through 3 nonlinear phases: open-ended elicitation, guided elicitation, and hypothesis-driven elicitation. Performing a comprehensive medical interview by obtaining background health information and the review of systems can help to expand or shrink the differential diagnosis. Clinicians should obtain information about specific symptoms and background information with a significant likelihood to narrow the differential diagnosis.
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Affiliation(s)
- Jessica J Dreicer
- Department of Medicine, University of Virginia, Charlottesville, VA, USA.
| | - Andrew S Parsons
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Joseph Rencic
- Department of Medicine, Boston University, Boston, MA, USA
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Affiliation(s)
- Raja-Elie E Abdulnour
- From the University of Virginia School of Medicine and UVAHealth, Charlottesville (A.S.P.); and Boston Medical Center and Boston University School of Medicine, Boston (J.R.)
| | - Andrew S Parsons
- From the University of Virginia School of Medicine and UVAHealth, Charlottesville (A.S.P.); and Boston Medical Center and Boston University School of Medicine, Boston (J.R.)
| | - Daniel Muller
- From the University of Virginia School of Medicine and UVAHealth, Charlottesville (A.S.P.); and Boston Medical Center and Boston University School of Medicine, Boston (J.R.)
| | - Jeffrey Drazen
- From the University of Virginia School of Medicine and UVAHealth, Charlottesville (A.S.P.); and Boston Medical Center and Boston University School of Medicine, Boston (J.R.)
| | - Eric J Rubin
- From the University of Virginia School of Medicine and UVAHealth, Charlottesville (A.S.P.); and Boston Medical Center and Boston University School of Medicine, Boston (J.R.)
| | - Joseph Rencic
- From the University of Virginia School of Medicine and UVAHealth, Charlottesville (A.S.P.); and Boston Medical Center and Boston University School of Medicine, Boston (J.R.)
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17
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Affiliation(s)
- Andrew S Parsons
- director, Clinical Development and Coaching Program, Department of Medicine, University of Virginia
| | - Caitlin B Clancy
- director, Curricular Analytics, Innovation, and Technology, Department of Medicine, University of Pennsylvania
| | - Joseph J Rencic
- director, Clinical Reasoning and course codirector, Doctoring 2, Department of Medicine, Boston University
| | - Karen M Warburton
- director, Graduate Medical Education Remediation, Department of Medicine, University of Virginia
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18
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Parsons AS, Warburton KM, Martindale JR, Rosenberg IL. Characterization of Clinical Skills Remediation: A National Survey of Medical Schools. South Med J 2022; 115:202-207. [PMID: 35237839 DOI: 10.14423/smj.0000000000001361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Clinical skills instruction is a standard part of medical school curricula, but how institutions address learners who struggle in this area is less clear. Although recommendations for the remediation of clinical skills at an institutional level have been published, how these recommendations are being implemented on a national scale is unknown. In this descriptive study, we characterize current clinical skills remediation practices at US medical schools and US-accredited Caribbean medical schools. METHODS We conducted a cross-sectional survey of medical educators who work with struggling students. From March 24, 2020 to April 9, 2020, the Directors of Clinical Skills Remediation Working Group conducted an e-mail survey incorporating four aspects of remediation program design and function: identification, assessment, active remediation, and ongoing evaluation. RESULTS In total, 92 individuals representing 45 institutions provided descriptive information about their respective remediation programs. The majority of respondents have a formal process of identifying (75%) and assessing (86%) students who are identified as struggling with clinical skills, but lack a standardized method of categorizing deficits. Fewer institutions have a standardized approach to active remediation and ongoing evaluation of struggling learners. Fifty-two percent of institutions provide training to faculty involved in the remediation process. CONCLUSIONS Although most institutions are able to identify struggling students, they lack a standardized approach to intervene. Remediation effectiveness is limited by a lack of student buy-in and institutional time, expertise, and resources. These findings highlight the need for more formalized structure and standardization in remediation program design and implementation.
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Affiliation(s)
- Andrew S Parsons
- From the Departments of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, and the Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Karen M Warburton
- From the Departments of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, and the Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - James R Martindale
- From the Departments of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, and the Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Ilene L Rosenberg
- From the Departments of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, and the Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
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19
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Jaspan V, Schaye V, Parsons AS, Kudlowitz D. Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis. Diagnosis (Berl) 2021; 9:288-293. [PMID: 34882358 DOI: 10.1515/dx-2021-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 11/17/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome. CASE PRESENTATION This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1-2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome. CONCLUSIONS Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.
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Affiliation(s)
- Vita Jaspan
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Verity Schaye
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Andrew S Parsons
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - David Kudlowitz
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
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20
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Ford V, Frischtak H, Wiencek JR, Parsons AS. A High-Value Care Curriculum Using Individual and Group Structured Reflection. South Med J 2021; 114:797-800. [PMID: 34853857 DOI: 10.14423/smj.0000000000001325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE One-third of all healthcare dollars are wasted, primarily in the form of clinician-ordered unnecessary diagnostic tests and treatments. Medical education has likely played a central role in the creation and perpetuation of this problem. We aimed to create a curriculum for medical students to promote their contribution to high-value care conversations in the clinical environment. METHODS At a large university medical center between March 2017 and February 2018, we implemented a 3-phase curriculum combining multimodal educational initiatives with individual and group reflection for third-year medical students during their 12-week long Internal Medicine clerkship rotation. Students were asked to identify examples of clinical decision making that lacked attention to high-value care, propose solutions to the identified situation, and pinpoint barriers to the implementation of effective solutions using a structured reflection framework and then participate in a debrief debate with fellow students. To assess the curriculum, reflective narratives were coded by frequency and codes were compared with one another and with relevant high-value care literature to identify patterns and themes. RESULTS In total, 151 medical students participated in phase 1 and 119 in phase 3. For phase 2, 126 reflective narratives (94.7% participation rate) comprised 226 problems, 280 solutions, and 179 barriers. CONCLUSIONS When provided appropriate resources, medical students are able to identify relevant examples of low-value care, downstream solutions, and barriers to implementation through a structured reflection curriculum comprising written narratives and in-person debate.
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Affiliation(s)
- Vanessa Ford
- From the Department of Pediatrics, Emory University, Atlanta, Georgia, the Department of Family Medicine, Contra Costa Regional Medical Center, Martinez, California, the Department of Pathology, Vanderbilt University, Nashville, Tennessee, and the Department of Medicine, University of Virginia, Charlottesville
| | - Helena Frischtak
- From the Department of Pediatrics, Emory University, Atlanta, Georgia, the Department of Family Medicine, Contra Costa Regional Medical Center, Martinez, California, the Department of Pathology, Vanderbilt University, Nashville, Tennessee, and the Department of Medicine, University of Virginia, Charlottesville
| | - Joesph R Wiencek
- From the Department of Pediatrics, Emory University, Atlanta, Georgia, the Department of Family Medicine, Contra Costa Regional Medical Center, Martinez, California, the Department of Pathology, Vanderbilt University, Nashville, Tennessee, and the Department of Medicine, University of Virginia, Charlottesville
| | - Andrew S Parsons
- From the Department of Pediatrics, Emory University, Atlanta, Georgia, the Department of Family Medicine, Contra Costa Regional Medical Center, Martinez, California, the Department of Pathology, Vanderbilt University, Nashville, Tennessee, and the Department of Medicine, University of Virginia, Charlottesville
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21
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Walker T, Whalen LB, Vetter MJ, Parsons AS, Bray MJ, Gusic ME. Coaching medical students to confront racism in the clinical setting. Med Educ 2021; 55:1311-1312. [PMID: 34476829 DOI: 10.1111/medu.14645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 08/05/2021] [Indexed: 06/13/2023]
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22
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Clemo R, Parsons AS, Boggan JC, Shieh L, Miller BP. Learning by Doing: Practical Strategies to Integrate Resident Education and Quality Improvement Initiatives. J Grad Med Educ 2021; 13:631-634. [PMID: 34721789 PMCID: PMC8527936 DOI: 10.4300/jgme-d-21-00381.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Rebecca Clemo
- Rebecca Clemo, MD, is Chief Resident, Internal Medicine Residency Program, University of Virginia School of Medicine
| | - Andrew S. Parsons
- Andrew S. Parsons, MD, MPH, is Associate Program Director, Internal Medicine Residency Program, and Assistant Professor, Department of Medicine and Public Health Sciences, Section of Hospital Medicine, University of Virginia School of Medicine
| | - Joel C. Boggan
- Joel C. Boggan, MD, MPH, is Associate Program Director, Internal Medicine Residency Program, and Assistant Professor, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine
| | - Lisa Shieh
- Lisa Shieh, MD, PhD, is Clinical Professor of Medicine, Associate Chief Quality Officer, Medical Director of Quality, Department of Medicine, and Medical Director of GME QI programs, Stanford University School of Medicine
| | - Bahnsen P. Miller
- Bahnsen P. Miller, MD, is Assistant Professor, Department of Medicine, Section of Hospital Medicine, University of Virginia School of Medicine
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23
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Magee CD, Parsons AS, Millard AS, Torre D. Lessons in clinical reasoning ‒ pitfalls, myths, and pearls: a case of confusion, disequilibrium, and "picking at the air". Diagnosis (Berl) 2021; 9:127-132. [PMID: 34455730 DOI: 10.1515/dx-2020-0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/30/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. CASE PRESENTATION A 43-year-old female was brought to the emergency department with 4-5 days of confusion, disequilibrium resulting in several falls, and hallucinations. Further investigation revealed tachycardia, diaphoresis, mydriatic pupils, incomprehensible speech and she was seen picking at the air. Given multiple recent medication changes, there was initial concern for serotonin syndrome vs. an anticholinergic toxidrome. She then developed a fever, marked leukocytosis, and worsening encephalopathy. She underwent lumbar puncture and aspiration of an identified left ankle effusion. Methicillin sensitive staph aureus (MSSA) grew from blood, joint, and cerebrospinal fluid cultures within 18 h. She improved with antibiotics and incision, drainage, and washout of her ankle by orthopedic surgery. CONCLUSIONS Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts, this case underscores how multiple cognitive biases can cascade sequentially, skewing clinical reasoning toward erroneous conclusions and driving potentially inappropriate testing and treatment. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of structured reflection, a tool to promote metacognitive analysis, and the application of knowledge organization tools such as illness scripts to navigate these cognitive biases.
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Affiliation(s)
- Charles D Magee
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Andrew S Parsons
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | | | - Dario Torre
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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24
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Parsons AS, Kon RH, Plews-Ogan M, Gusic ME. You can have both: Coaching to promote clinical competency and professional identity formation. Perspect Med Educ 2021; 10:57-63. [PMID: 32804347 PMCID: PMC7429451 DOI: 10.1007/s40037-020-00612-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Coaching is a critical tool to guide student development of clinical competency and formation of professional identity in medicine, two inextricably linked concepts. Because progress toward clinical competence is linked to thinking, acting and feeling like a physician, a coach's knowledge about a learner's development of clinical skills is essential to promoting the learner's professional identity formation. A longitudinal coaching program provides a foundation for the formation of coach-learner relationships built on trust. Trusting relationships can moderate the risk and vulnerability inherent in a hierarchical medical education system and allow coaching conversations to focus on the promotion of self-regulated learning and fostering skills for life-long learning. Herein, we describe a comprehensive, longitudinal clinical coaching program for medical students designed to support learners' professional identify formation and effectively promote their emerging competence.
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Affiliation(s)
- Andrew S Parsons
- Department of Medicine, University of Virginia School of Medicine, 1215 Lee St., 22908-0422, Charlottesville, VA, USA.
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Rachel H Kon
- Department of Medicine, University of Virginia School of Medicine, 1215 Lee St., 22908-0422, Charlottesville, VA, USA
| | - Margaret Plews-Ogan
- Department of Medicine, University of Virginia School of Medicine, 1215 Lee St., 22908-0422, Charlottesville, VA, USA
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25
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Wiencek JR, Head CL, Sifri CD, Parsons AS. Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center. Open Forum Infect Dis 2020; 7:ofaa406. [PMID: 33072813 PMCID: PMC7553244 DOI: 10.1093/ofid/ofaa406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/28/2020] [Indexed: 11/12/2022] Open
Abstract
Background The novel severe acute respiratory coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) originated in December 2019 and has now infected almost 5 million people in the United States. In the spring of 2020, private laboratories and some hospitals began antibody testing despite limited evidence-based guidance. Methods We conducted a retrospective chart review of patients who received SARS-CoV-2 antibody testing from May 14, 2020, to June 15, 2020, at a large academic medical center, 1 of the first in the United States to provide antibody testing capability to individual clinicians in order to identify clinician-described indications for antibody testing compared with current expert-based guidance from the Infectious Diseases Society of America (IDSA) and the Centers for Disease Control and Prevention (CDC). Results Of 444 individual antibody test results, the 2 most commonly described testing indications, apart from public health epidemiology studies (n = 223), were for patients with a now resolved COVID-19-compatible illness (n = 105) with no previous molecular testing and for asymptomatic patients believed to have had a past exposure to a person with COVID-19-compatible illness (n = 60). The rate of positive SARS-CoV-2 antibody testing among those indications consistent with current IDSA and CDC guidance was 17% compared with 5% (P < .0001) among those indications inconsistent with such guidance. Testing inconsistent with current expert-based guidance accounted for almost half of testing costs. Conclusions Our findings demonstrate a dissociation between clinician-described indications for testing and expert-based guidance and a significantly different rate of positive testing between these 2 groups. Clinical curiosity and patient preference appear to have played a significant role in testing decisions and substantially contributed to testing costs.
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Affiliation(s)
- Joesph R Wiencek
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA.,Laboratory Stewardship Committee, University of Virginia Health, Charlottesville, Virginia, USA
| | - Carter L Head
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Costi D Sifri
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.,Office of Hospital Epidemiology, University of Virginia Health, Charlottesville, Virginia, USA
| | - Andrew S Parsons
- Department of Medicine, Section Hospital Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Abstract
Management reasoning, a component of clinical reasoning, has become an important area for medical education research given its inherent complexity, role in medical decision making, and association with high-value care. Teaching management reasoning requires characterizing its core concepts and identifying strategies to teach them. In this Perspective, the authors propose the term "management script" to describe the mental schema that clinicians develop and use in medical decision making. Management scripts are high-level, precompiled, conceptual knowledge structures of the courses of action that a clinician may undertake to address a patient's health care problem(s). Like illness scripts, management scripts have foundational elements that are shared by most clinicians but are ultimately idiosyncratic based on each clinician's unique history of learning and experience. Applying management scripts includes 2 steps-(1) management script activation and (2) management option selection-which can occur reflexively (unconsciously) or deliberately (consciously), similar to, respectively, the System 1 thinking and System 2 thinking of dual process theory. Management scripts can be taught for different conditions by using management script templates, educational scaffolds that provide possible courses of action to address a health care problem at any stage. Just as learners use system-based or organ-based frameworks to generate a differential diagnosis, students can use a generic management script template early in training to develop management scripts for specific problems. Future research directions include exploring the role of management scripts in medical education and quality improvement practices.
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Affiliation(s)
- Andrew S Parsons
- A.S. Parsons is assistant professor of medicine and public health sciences, Department of Medicine, associate program director, Internal Medicine Residency Program, and director, Clinical Skills Course and Pre-clerkship Coaching, University of Virginia School of Medicine, Charlottesville, Virginia; ORCID: http://orcid.org/0000-0001-5631-9465
| | - Thilan P Wijesekera
- T.P. Wijesekera is assistant professor of medicine, Department of Medicine, director, Clinical Reasoning, and associate director, Educator Development in Clinical Reasoning, Teaching and Learning Center, Yale University School of Medicine, New Haven, Connecticut; ORCID: http://orcid.org/0000-0002-2473-424X
| | - Joseph J Rencic
- J.J. Rencic is associate professor of medicine, Department of Medicine, and director of clinical reasoning and course co-director, Doctoring 2, Boston University School of Medicine, Boston, Massachusetts; ORCID: http://orcid.org/0000-0002-2598-3299
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27
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Brennan GT, Parsons AS. A Case for Abandoning Inpatient Fecal Occult Blood Testing. Cureus 2020; 12:e8807. [PMID: 32724753 PMCID: PMC7381841 DOI: 10.7759/cureus.8807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Fecal occult blood testing (FOBT) is currently Food and Drug Administration (FDA) approved only for colorectal cancer (CRC) screening. There is now widespread off-label use of FOBT in the hospital setting as a diagnostic test. Here we present a brief case and a more detailed review of the literature arguing against inpatient FOBT. Inpatient use of FOBT is problematic for several reasons including failure to account for false positives or negatives, delays in appropriate consultations or endoscopy, increased costs, increase length of stays, unnecessary procedures, and test results that do not change management. Inappropriate use of FOBT can lead to both overuse and underuse of endoscopy. Many retrospective audit studies and more recently a meta-analysis have shown that FOBTs have poor test performance and are unable rule out the need for endoscopy in patients with iron deficiency anemia. For these reasons we argue that inpatient FOBT should be abandoned.
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Affiliation(s)
- Scott M Seki
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Katharine C DeGeorge
- Department of Family Medicine, University of Virginia, Charlottesville, Virginia, USA
| | | | - Andrew S Parsons
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
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29
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Parsons AS, Burger A, Pahwa AK. Clinical Guideline Highlights for the Hospitalist: Diagnosis and Management of Clostridium difficile in Adults. J Hosp Med 2020; 15:95-96. [PMID: 31532745 DOI: 10.12788/jhm.3300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Andrew S Parsons
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Alfred Burger
- Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amit K Pahwa
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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30
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Walker M, Warburton KM, Rencic J, Parsons AS. Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of chest pain and shortness of breath. Diagnosis (Berl) 2019; 6:387-392. [DOI: 10.1515/dx-2019-0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/10/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. A metacognitive structured reflection on what clinical findings fit and/or do not fit with likely and “can’t miss” diagnoses may reduce such errors.
Case presentation
A 57-year-old man was sent to the emergency department from clinic with chest pain, severe shortness of breath, weakness, and cold sweats. Further investigation revealed multiple risk factors for coronary artery disease, sudden onset of exertional dyspnea, and chest pain that incompletely resolved with rest, mild tachycardia and hypoxia, an abnormal electrocardiogram (ECG), elevated serum cardiac biomarkers, and elevated B-type natriuretic peptide (BNP) in the absence of left-sided heart failure. He was treated for acute coronary syndrome (ACS), discharged, and quickly returned with worsening symptoms that eventually led to a diagnosis of submassive pulmonary embolism (PE).
Conclusions
Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts at two institutions, this case underscores the importance of frequent assessment of fit along with explicit explanation of dissonant features in order to avoid premature closure and diagnostic error. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of diagnostic schema as an analytic reasoning strategy to assist in the creation of a differential diagnosis, problem representation to summarize updated findings, a Popperian analytic approach of attempting to falsify less-likely hypotheses, and matching pertinent positives and negatives to previously learned illness scripts. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl specific to premature closure.
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Affiliation(s)
- McCall Walker
- University of Virginia , Department of Medicine , Charlottesville , USA
| | | | - Joseph Rencic
- Tufts Medical Center , Department of Medicine , Boston, MA , USA
| | - Andrew S. Parsons
- University of Virginia , Department of Medicine , 1215 Lee Street , Charlottesville, VA 22903-1738 , USA , Phone: +4236201398
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31
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Eschenbacher WH, Marino A, Hoke G, Parsons AS. A just-in-time tool for teaching high-value care. Med Educ 2019; 53:1143. [PMID: 31650608 DOI: 10.1111/medu.13985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Cho HJ, Parsons AS. Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing?-Reply. JAMA Intern Med 2018; 178:431-432. [PMID: 29507988 DOI: 10.1001/jamainternmed.2017.8531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Hyung J Cho
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrew S Parsons
- Section of Hospital Medicine, Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville
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33
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Eaton KP, Levy K, Soong C, Pahwa AK, Petrilli C, Ziemba JB, Cho HJ, Alban R, Blanck JF, Parsons AS. Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing. JAMA Intern Med 2017; 177:1833-1839. [PMID: 29049500 DOI: 10.1001/jamainternmed.2017.5152] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Routine daily laboratory testing of hospitalized patients reflects a wasteful clinical practice that threatens the value of health care. Choosing Wisely initiatives from numerous professional societies have identified repetitive laboratory testing in the face of clinical stability as low value care. Although laboratory expenditure often represents less than 5% of most hospital budgets, the impact is far-reaching given that laboratory tests influence nearly 60% to 70% of all medical decisions. Excessive phlebotomy can lead to hospital-acquired anemia, increased costs, and unnecessary downstream testing and procedures. Efforts to reduce the frequency of laboratory orders can improve patient satisfaction and reduce cost without negatively affecting patient outcomes. To date, numerous interventions have been deployed across multiple institutions without a standardized approach. Health care professionals and administrative leaders should carefully strategize and optimize efforts to reduce daily laboratory testing. This review presents an evidence-based implementation blueprint to guide teams aimed at improving appropriate routine laboratory testing among hospitalized patients.
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Affiliation(s)
- Kevin P Eaton
- Department of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kathryn Levy
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Christine Soong
- Division of General Internal Medicine, Department of Medicine, Sinai Health System, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Amit K Pahwa
- Division of General Internal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Christopher Petrilli
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.,The Michigan Medicine/Institute for Healthcare Policy and Innovation for Program on Value Enhancement, Ann Arbor
| | - Justin B Ziemba
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Hyung J Cho
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rodrigo Alban
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jaime F Blanck
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew S Parsons
- Section of Hospital Medicine, Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville
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Wallace BB, Millward D, Parsons AS, Davis RH. Unrestricted access by general practitioners to a department of diagnostic radiology. J R Coll Gen Pract 1973; 23:337-43. [PMID: 4749951 PMCID: PMC2157091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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