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
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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)