Teaching Students How to Think: A Longitudinal Qualitative Study of Preclerkship Clinical Reasoning Instruction

INTRODUCTION

An objective of undergraduate medical education is to teach students how to think like physicians through a process called clinical reasoning. Currently, clerkship directors often feel that students enter their clinical years with a marginal comprehension of clinical reasoning concepts; instruction in this area could be improved. Although there have been previous educational studies assessing curricular interventions to improve the instruction of clinical reasoning, it is not yet known what happens at an individual level between an instructor and a small group of students in the teaching of clinical reasoning. This research will identify how clinical reasoning is being taught in a longitudinal clinical reasoning course.

METHODS

The Introduction to Clinical Reasoning course is a 15-month-long case-based course held in the preclinical curriculum of the USU. Individual sessions involve small-group learning with approximately seven students per group. Throughout the academic year of 2018-2019, 10 of these sessions were videotaped and transcribed. All participants provided informed consent. A thematic analysis was performed using a constant comparative approach. Transcripts were analyzed until thematic sufficiency was reached.

RESULTS

Over 300 pages of text were analyzed; new themes ceased to be identified after the eighth session. Topics included obstetrics, general pediatric issues, jaundice, and chest pain; these sessions were taught either by attendings, fellows, or fourth-year medical students with attending supervision. The thematic analysis revealed themes associated with clinical reasoning processes, themes associated with knowledge organization, and a theme associated with clinical reasoning in the military. The clinical reasoning process themes included problem list construction and refinement, differential diagnosis, naming and defending a leading diagnosis, and clinical reasoning heuristics. The knowledge organization themes included illness script development and refinement and semantic competence. The final theme was military relevant care.

CONCLUSIONS

In individual teaching sessions, preceptors emphasized problem lists, differential diagnoses, and leading diagnoses in a course designed to strengthen diagnostic reasoning in preclerkship medical students. The use of illness scripts was more often implicitly used rather than explicitly stated, and students used these sessions to use and apply new vocabularies related to a clinical presentation. Instruction in clinical reasoning could be improved by encouraging faculty to provide further context to their thinking, by encouraging the comparing and contrasting of illness scripts, and by using a shared vocabulary for clinical reasoning. Limitations of this study include that it was done in the context of a clinical reasoning course and that it was done at a military medical school, which may limit generalizability. Future studies could determine if faculty development could improve the frequency of references to the clinical reasoning processes that could improve student readiness for clerkship.

Treatment of Patients Hospitalized with COVID-19 in a US Military Role 3 Facility in Afghanistan: A Case Series

BACKGROUND

COVID-19, caused by SARS CoV-2, is an acute respiratory viral illness. We present the experience of treating patients hospitalized with COVID-19 in a Role 3 hospital in an active warzone.

METHODS

This is a retrospective care series of patients treated for COVID-19 at Craig Joint Theater Hospital, Bagram, Afghanistan from May to August 2020. Data extracted included demographics, admission and disposition information, past medical history, comorbidities, Transportation Command (TRANSCOM) severity classification (i.e. Category A, Category B), and treatments received.

RESULTS

This series included 15 Category A and 55 Category B patients. Most patients were non-US contractors with one chronic condition. Most patients received medical treatments in accordance with Department of Defense Practice Management Guidelines. For Category A patients, mechanical ventilation use declined from a mean average of 10.67 days to 2.83 days following the introduction of high-flow nasal cannula. Average hospital length of stay was 6 days (range 2-23). One death occurred in a patient greater than 60 years old with three known prior medical conditions. Most patients were discharged to a non-medical isolation facility. Aeromedically evacuated patients were mostly US military and US contractors.

CONCLUSION

We faced several challenges including retrofitting a Role 3 facility designed for trauma care for management of a highly contagious respiratory viral illness. Logistics constraints impacted timely delivery of medical therapies and equipment and decreased efficiency of aeromedical evacuation. Despite these challenges and the simultaneous trauma mission, most patients received medical care in accordance with treatment guidelines with a low mortality rate.

Statin-Induced Immune-Mediated Necrotizing Myopathy: An Increasingly Recognized Inflammatory Myopathy

Statin-induced immune-mediated necrotizing myopathy, also known as anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) myopathy, is an inflammatory myopathy that is triggered by statin exposure and persists after statin discontinuation. It is a rare side effect of statins, distinct from the more commonly recognized statin-induced myalgia, that is challenging to diagnose and treat. We describe a case of anti-HMGCR myopathy in a 59-year-old male with a prior history of statin intolerance presenting with markedly elevated creatinine kinase, myoglobinuria, and one month of progressive proximal muscle weakness after restarting atorvastatin 10 months prior to admission. High-dose glucocorticoids led to rapid clinical improvement, although the patient relapsed upon tapering. Remission was attained at three months after combination therapy with azathioprine, intravenous immunoglobulin, and a prolonged prednisone taper. 

Reducing the Inappropriate Use of Proton Pump Inhibitors in an Internal Medicine Residency Clinic

Introduction

Proton pump inhibitors (PPI) are commonly prescribed in the primary care setting. While generally considered to be safe, there is growing evidence suggesting that PPI misuse is associated with a variety of significant adverse outcomes and unnecessary cost. The goal of this quality improvement project was to identify patients with non-guideline recommended PPI prescriptions in our internal medicine residency clinics and implement a process to de-prescribe or reduce the dose of PPIs across this patient population.

Methods

PPI prescription rates, dosage, and indication were extracted from the medical records of all 854 patients empaneled to the internal medicine residency clinics at a multicenter closed referral military hospital system. Appropriate PPI indication was consensus based upon published guidelines, and patients without an appropriate indication were targeted for intervention. These patients were directly contacted by their primary care physicians, via phone or during a clinic visit, to discuss the risks and benefits of ongoing PPI use as well as alternative therapies or tapering regimens at the physician’s discretion. For moderate to high dose PPI, the dose was decreased by 50% every week until the lowest tolerated dose was achieved or until discontinuation. For low dose PPI, discontinuation was recommended as the initial intervention. Six months following the intervention, the empanelment was reevaluated for ongoing PPI usage, tapered dosage, or discontinuation.

Results

Of a total of 854 patient records reviewed at the initiation of the project, 322 patients were noted to be prescribed PPIs. Of this subset, 66% (217/322) did not meet a guideline recommended indication for their use. At the completion of the six-month intervention period, 44% (96/217) of patients were successfully weaned to a reduced dose or were no longer using a PPI.

Conclusions

PPIs are widely used and generally considered to be a well-tolerated therapy for acid-secretion disorders. PPI overprescription and the associated adverse effects and economic burden are increasingly recognized. We show that a simple, focused, resident-driven quality improvement intervention can be effective in de-prescribing efforts to reduce inappropriate PPI use in the outpatient primary care setting.

Tranexamic Acid Use in a Patient with a Life-threatening Bleed Exacerbated by Coagulopathy Due to an Aortic Aneurysm with an Endoleak: A Case Report

Tranexamic acid (TXA) is an anti-fibrinolytic agent that inhibits plasminogen activation by binding to its lysine receptor sites and preventing its conversion to plasmin. It stabilizes clots to reduce bleeding and has been used in the setting of trauma, heavy menstrual bleeding, and hematologic malignancies. To our knowledge, there is no mention in the literature of medical management with TXA to treat a life-threatening hemorrhage in the setting of non-operative, endoleakage-induced, chronic disseminated intravascular coagulation (DIC). This case report summarizes the successful use of TXA in a patient with DIC secondary to multiple aortic aneurysms and endoleakage in an effort to stop the expansion of a life-threatening gluteal hematoma not amenable to surgical or vascular intervention.

Accuracy of traditional age, gender and symptom based pre-test estimation of angiographically significant coronary artery disease in patients referred for coronary computed tomographic angiography

Determining the pretest probability of angiographically significant (≥50% stenosis) coronary artery disease (CAD) in symptomatic patients relies on the Diamond and Forrester (DF) classification, which was derived from a cohort referred for invasive coronary angiography. The accuracy of this approach in patients referred for noninvasive coronary angiography is not fully known. Consecutive patients without known CAD referred for coronary computed tomographic angiography (CCTA) were evaluated. Chest pain was prospectively categorized as nonanginal, atypical angina, typical angina, or asymptomatic. The pretest likelihood of angiographically significant CAD was estimated using DF classification and compared with observed rates of angiographically significant CAD on CCTA. Among 1,027 patients (41% women; mean age 50 ± 12 years), 38 (4%) had nonanginal symptoms, 643 (63%) had atypical angina, 72 (7%) had typical angina, and 274 (26%) were asymptomatic. The prevalence of angiographically significant CAD in patients with nonanginal chest pain, atypical angina, typical angina, and no symptoms was 1 (3%), 55 (9%), 14 (19%), and 25 (9%), respectively (p <0.001). DF classification significantly overestimated angiographically significant CAD prevalence across all symptom classifications, genders, and ages despite adjustment for risk factors (p <0.001 for all comparisons). DF classification had an area under the receiver-operating characteristic curve of 0.72 (95% confidence interval 0.66 to 0.78), which was not significantly different from age alone (0.69) or age, symptoms, and risk factors (0.68). In conclusion, in a low- to intermediate-risk cohort referred for CCTA, DF classification significantly overestimated angiographically significant CAD prevalence across all age, gender, and symptom strata. The DF classification may overestimate the pretest probability of angiographically significant CAD in contemporary patients referred for CCTA.

Mercy health promoters: a paradigm for implementing third world practices for resource-poor conditions of the developed world

The foreign-born population in the United States, according to the "Current Populations Report" published in 2004, is estimated to exceed 33.5 million, or "11.7 percent of the U.S. population". The increase in foreign-born peoples and their need for health care is a complicated issue facing many cities, health systems and hospitals. Over the course of the past few years Mercy Hospital of Philadelphia has treated increasing numbers of foreign-born African patients. The majority have been presenting in the late stages of disease. The increase of foreign-born documented and undocumented African patients seen by Mercy Hospital seems to reflect a foreign-born population "boom" in Philadelphia over the past decade. To meet the needs of this growing population, the Mercy Hospital Task Force on African Immigration designed a program that centers on the developing world concept of "Health Promoters". This program is intended to serve as one possible solution for hospitals to cost-effectively manage the care of this growing percentage of foreign-born individuals in the population. This notion of a "Health Promoter" program in Philadelphia is unique as one of those rare occasions when a developing world concept is being utilized in a developed world environment. It is also unique in that it can serve as a paradigm for other hospitals in the United States to meet the growing need of health care for the undocumented population.