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Teaching and Assessing

Critical Reasoning in the Era of


Competency-based Medical
Education, Milestones and
Entrustment

Preventing Diagnostic Error






Were pretty sure its the West Nile virus.

Clinical Reasoning: A Primer
Patient/situation
characteristics
Prior knowledge
Problem Representation
Information Gathering
Context
Evaluation Action
Gruppen and Frohna, International Handbook on Research, 2002

Clinical Reasoning
Internal process
Trainees and faculty need ways to
externalize and teach this process
Programs need assessment methods that
document growth and competency in this skill

Critical Thinking
Good Thinking
Sensitivity
Interest in gaining
more information
Seeking
alternatives
Inclination
Willing to invest
energy in thinking
the matter through
Ability
Possess the
cognitive ability

Bad Thinking
cognitive misers
Chose to take mental
shortcuts, engage in
heuristic thinking,
without interest in
good thinking
Krupat 2011


Adverse Events and Clinical Reasoning
Graber adverse event study:
Most errors combination of individual and
systems factors
Average 5.9 system +/- cognitive error per case
Cognitive factors
320 cognitive factors in 74 cases
45 due to faulty data gathering
264 due to faulty synthesis (problem
representation clinical reasoning)
Arch Intern Med. 2005; 165: 1493.
The Process of Clinical
Reasoning
How can clinical reasoning be
taught and assessed in a
competency-based system to
reduce diagnostic error?
CBME - a new paradigm
You must truly know the trainee has
demonstrated competence and is ready to
progress to the next stage of their training or
career:
Requires clear definition of expected
outcomes (good thinking with decrease in
diagnostic errors)
Requires assessment and evaluation systems
capable of demonstrating that these things are
done consistently and within the contextual
needs of the clinical environment
Requirements

The content of good thinking
Define the K/S/A of good thinking and frame as
an entrustment
An assessment and evaluation system
Faculty Development creating a shared
mental model or understanding of good
thinking and how it is assessed and evaluated
The Content - Twelve Tips to prevent
diagnostic error
Understand heuristics
Use diagnostic timeouts
Think worst-case scenario medicine
Systematic approach to common problems
Ask why
Teach/emphasize physical exam
Teach Bayesian theory
Acknowledge your emotions
Identify what doesnt fit
Embrace zebras
Slow down
Admit mistakes
Trowbridge Medical Teacher 2008
The Twelve Tips and the Internal Medicine
Curricular Milestones

142 discrete milestones published in 2009
Describe developmentally the discrete K/S/A
needed for competency in the six ACGME
General Competencies
Cross walking the 12 tips against the milestones
identifies at least 28 milestones that capture the
knowledge, skills or attitudes that could be used
to teach and assess critical reasoning.
Patient Care
ACGME
Competency
Developmental Milestones
Informing
ACGME Competencies
Approximate
Time Frame
Trainee to
Achieve
Stage
Assessment
Methods/Tools
Clinical skills and
reasoning
Manages
patients using
clinical skills of
interviewing
and physical
examination
Historical Data Gathering
1. Acquire accurate and relevant history
from the patient in an efficiently
customized, prioritized, and
hypothesis driven fashion
2. Seek and obtain appropriate, verified,
and prioritized data from secondary
sources (e.g. family, records,
pharmacy)
3. Obtain relevant historical subtleties
that inform and prioritize both
differential diagnoses and diagnostic
plans, including sensitive,
complicated, and detailed information
that may not often be volunteered by
the patient


6 months



9 months



18 months







Standardized
patient
Direct
Observation
Simulation
Sub-
competency
Entrustment in Medical Education
Focused assessments around what faculty
and training programs entrust trainees to
do?

Think critically to minimize error

Reflects the most important outcome of
training: a trainees readiness to bear
professional responsibility






http://www.im.org/AcademicAffairs/milestones/Pages/default.aspx
How do I develop an assessment?
Step 1 Describe the activity. What tasks
constitute the entrustment.

Step 2 Identify the Curricular Milestones (142)
that will help you assess a resident performing this
activity.

Step 3 Identify specific assessment methods /
tools to which you can apply the chosen Curricular
Milestones.
Clinical Reasoning

Step 1 Describe the activity. What tasks are
required for you to entrust this activity to a
resident?

The Good Thinker as described by the
twelve tips cross walked to the Internal Medicine
Curricular Milestones.





Twelve Tips to prevent diagnostic error
The Good Thinker Entrustment
Understand heuristics
Use diagnostic timeouts
Think worst-case scenario medicine
Systematic approach to common problems
Ask why
Teach/emphasize physical exam
Teach Bayesian theory
Acknowledge your emotions
Identify what doesnt fit
Embrace zebras
Slow down
Admit mistakes
Trowbridge Medical Teacher 2008
Clinical Reasoning
Step 2 Identify the Curricular Milestones (142)
that will help you assess a resident performing this
activity

Key Considerations:
What Curricular Milestones are best assessed in this
setting? in this context?
You dont have to choose all milestones, only those
that will help you to see competence in the trainee.
Crosswalk the twelve tips and the 142 curricular
milestones.
Understand heurisitcs
1. MK -1- Demonstrate sufficient knowledge to diagnose and treat undifferentiated and
emergent conditions
Use diagnostic timeouts
1. PC 3 - Modify differential diagnosis and care plan based upon clinical course and data as
appropriate
2. PBLI 6 - Actively seek feedback from all members of the health care team
3. PBLI 6 - Calibrate self-assessment with feedback and other external data
4. PBLI 6 - Reflect on feedback in developing plans for improvement
Think worst-case scenario medicine
1. MK 1 - Understand the relevant pathophysiology and basic science for uncommon or
complex medical conditions
2. MK 1 - Demonstrate sufficient knowledge to evaluate complex or rare medical conditions
and multiple coexistent conditions
3. PC 6 - Manage complex or rare medical conditions
Systematic approach to common problems
1. PC 3 - Synthesize all available data, including interview, physical examination, and
preliminary laboratory data, to define each patients central clinical problem
2. MK 1 Demonstrate sufficient knowledge to evaluate common ambulatory conditions
3. MK 1 - Demonstrate sufficient knowledge to diagnose and treat common conditions that
require hospitalization
Ask why
1. PBLI 2 - Classify and precisely articulate clinical questions
2. PBLI 2 - Develop a system to track, pursue, and reflect on clinical questions
Teach/emphasize physical exam
1. PC 1 - Obtain relevant historical subtleties that inform and prioritize both differential
diagnoses and diagnostic plans, including sensitive, complicated, and detailed information
that may not often be volunteered by the patient
2. PC 2 - Routinely identify subtle or unusual physical findings that may influence clinical
decision making, using advanced maneuvers where applicable
Teach Bayesian theory
1. MK 2 - Understand prior probability and test performance characteristics
2. SBP 5 - Minimize unnecessary care including tests, procedures, therapies and ambulatory or
hospital encounters
3. SPB 4 - - Understand how cost-benefit analysis is applied to patient care (i.e. via principles of
screening tests and the development of clinical guidelines)
Acknowledge your emotions
1. P 6 - Recognize and address personal, psychological, and physical limitations that may affect
professional performance
2. P 9 - Recognize and manage conflict when patient values differ from their own
3. P 5 - Recognize and manage subtler conflicts of interest
Identify what doesnt fit
1. PBLI 5 - Determine if clinical evidence can be generalized to an individual patient
2. Patient care 3 - Recognize disease presentations that deviate from common patterns and
that require complex decision making
Embrace zebras
1. MK 1 - Understand the relevant pathophysiology and basic science for uncommon or
complex medical conditions
2. PK 6 - Manage complex or rare medical conditions
Slow down
1. Maintain awareness of the situation in the moment, and respond to meet situational needs
2. Reflect (in action) when surprised, applies new insights to future clinical scenarios, and
reflects (on action) back on the process
Admit mistakes
1. P 1 - Accept personal errors and honestly acknowledge them
Clinical Reasoning
Step 3 Identify specific assessment methods /
tools to which you can apply the chosen Curricular
Milestones.
Key Considerations:
What Curricular Milestones are best assessed in this
setting? in this context?
You dont have to choose all milestones, only those
that will help you to see competence in the trainee
Methods
Portfolio with required defense by learner
Case log
Focused narrative writing
Admit mistakes
Chart stimulated recall
Structured questioning regarding the twelve tips
milestones
Bedside rounds
One minute preceptor
Time out
Please check ONLY ONE box per statement Y N NA
Clear chief complaint
Delineation of sick vs non-sick
Appropriate history
Appropriate physical
Appropriate analysis of lab data
Appropriate differential diagnosis
Appropriate thought process for differential diagnosis
Treatment appropriate for diagnosis
Appropriate thought process for treatment plan
Overall Note:
Clarity____________________________________
Organization__________________________________
Internal consistency____________________________________
Documentation____________________________________
The One Minute Preceptor A Strategy
For Busy Clinicians

Clinical teaching strategy
5 microskills
Get a commitment
Probe for supporting evidence
Teach a general rule
Reinforce what was done right
Correct mistakes
Create time for reflection
Neher, Gordon, Meyer, Stevens. J Am Board Fam Pract
1992; 5:419-24.
The System
The Donobedian Framework
Schematic representation of a system
Every system has a structure and a process
that processes that produce an outcome
S + P = O
S(the when/where) + P (the teaching and
assessing) = O (Good thinkers)

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