PELC: “Creating a Culture of Clinical Reasoning: Tips for Educators” by Thilan Wijesekera, MD, MHS
November 06, 2023Information
“Creating a Culture of Clinical Reasoning: Tips for Educators” by Thilan Wijesekera, MD, MHS
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- 00:00We've got, let's see, we are recording,
- 00:04I see Catherine on here Dungen, great.
- 00:07And so again we tend to
- 00:09kind of filter in slowly.
- 00:11So wanted to introduce everybody to
- 00:15one of the members of our education
- 00:20leadership in the school. You know,
- 00:26Felon and I I practice this very often.
- 00:32Wish a second wish a Sacre, am I?
- 00:36Hopefully there.
- 00:38Benita, you're putting so
- 00:40much pressure on yourself.
- 00:41I'm happy to finish my introduction
- 00:42as well and get started.
- 00:44I'm excited to be here,
- 00:46but I'm actually going to give a little
- 00:48bit more than introductions here.
- 00:50And so Dylan got his MD from the University
- 00:53University of Rochester School of Medicine.
- 00:57He did residency training at our at
- 01:00Yale's primary care residency program.
- 01:03And then Phelan did a general internal
- 01:06medicine fellowship in medical
- 01:08education at Yale and then also got his
- 01:13MEHSMED in our institution.
- 01:182018, he joined the academic
- 01:22hospitalist program in Yale's
- 01:25General Internal Medicine program.
- 01:28He's very active in medical education.
- 01:31He's the director of Clinical Reasoning
- 01:33at the Teaching and Learning Center.
- 01:36He's an associate for Clinical
- 01:38Reasoning Educator Development,
- 01:40And so he provides consultations,
- 01:43workshops, and scholarship related
- 01:46to teaching clinical reasoning.
- 01:48And his research interests
- 01:51include clinical reasoning,
- 01:52diagnostic error with publications
- 01:55and academic medicine,
- 01:57medical Teacher,
- 01:58and the Journal of General Internal Medicine.
- 02:01And so with that introduction,
- 02:06all yours. Awesome.
- 02:07Thank you so much Pernina,
- 02:09and it's great having all of y'all here.
- 02:12I know that you are in between
- 02:15things often times with lunch,
- 02:18so feel free to eat and chat.
- 02:19But I will say part of my one of
- 02:22my favorite parts of these sessions
- 02:24is just the conversations we can
- 02:26have and learning from each other.
- 02:28And especially in your experience
- 02:30'cause I give these workshops
- 02:32to different departments where
- 02:34obviously it's not my expertise,
- 02:36but yeah, we're going to talk
- 02:39about strategies for evaluating
- 02:41and teaching clinical reasoning.
- 02:43I. So for the CME credit,
- 02:47make sure to text
- 02:5042047 to the Yale CME number and that'll
- 02:56be put in the chat again. Again, that's
- 03:0042047. Just a quick disclosure for me.
- 03:04So I am a consultant for the National
- 03:06Board of Medical Examiners around like
- 03:09developing assessments for management,
- 03:11reasoning, an area of my research and
- 03:13something we'll touch on a little bit.
- 03:15But just for your note, So what are
- 03:19we going to be talking about today?
- 03:213 broad aims for our workshops
- 03:23that I usually talk about, One,
- 03:25why clinical reasoning matters and
- 03:28some broad information terms around it,
- 03:302 how do we assess clinical
- 03:33reason in the clinical setting.
- 03:35You know, it's interesting.
- 03:36I've been giving a lot of workshops with
- 03:38colleagues across the country for this.
- 03:40I always like to pair assessment
- 03:42before teaching just because,
- 03:44like diagnosing the learner,
- 03:47no pun intended,
- 03:48can be so helpful for deciding what to teach.
- 03:50Because I know a lot of people don't
- 03:52necessarily have a lot of time when you
- 03:54are in your clinical settings with all
- 03:55the patients that you have to see as well.
- 03:58And we'll practice with a couple role plays
- 04:01for both assessing and teaching strategies.
- 04:04And I'd love to hear and encourage
- 04:07you to share what you're thinking
- 04:09about for these hypothetical learners
- 04:11in these situations.
- 04:13So let's start talking about
- 04:15clinical reasoning, epidemiology,
- 04:16terminology, and theory.
- 04:18So why does clinical reasoning matter?
- 04:21So we've been talking about
- 04:23clinical reasoning for decades.
- 04:24The literature becomes like pretty
- 04:27robust as of like 40 years ago.
- 04:30But what really started to pick up steam
- 04:32and interest around the topic is the
- 04:35National Academy of Medicine report
- 04:36Improving Diagnosis in healthcare,
- 04:38which came out in 2015 and 16.
- 04:41Then in this report it summarized
- 04:43the literature.
- 04:43The diagnostic errors happen a lot,
- 04:46anywhere from 10 to 15% of the counters
- 04:49in the more cognitive specialties.
- 04:50So medicine, internal medicine,
- 04:53Pediatrics, emergency medicine,
- 04:54maybe less so in some of the
- 04:57perceptual specialities,
- 04:58something like a radiology and pathology.
- 05:00And these have been consistently
- 05:03shown across various forms of study.
- 05:06Chart review being the most common
- 05:08types of study and they can have
- 05:10a significant impact.
- 05:11Various back in the envelope mass have
- 05:14used numbers estimating that it could.
- 05:17The diagnostic errors happened
- 05:19to literally everyone.
- 05:21The mortality,
- 05:21all the numbers depending on how
- 05:23you want to define diagnostic
- 05:24errors and the harm they cause,
- 05:25can go up and down from that 40 to 80,000
- 05:29number yearly in the US that I mentioned.
- 05:32And what makes clinical reasoning so
- 05:34important in this process is that
- 05:37when we have looked at diagnostic
- 05:38errors and I was actually a part of
- 05:41one of these chart review studies
- 05:43affiliated with UCSF here and about
- 05:4770% of them have been affiliated to
- 05:50be cognitive in some form or another,
- 05:53which is why we like to teach
- 05:55about clinical reasoning.
- 05:56Now,
- 05:56clinical reasoning can be
- 05:58defined in many different ways,
- 06:00ranging from broadly problem
- 06:02solving to critical thinking,
- 06:05sometimes more gestalt,
- 06:07like this learner's judgement
- 06:09that I'm observing right now,
- 06:12but the way I like to define it,
- 06:15and it's not particularly the new definition.
- 06:17This is from Kevin Eva,
- 06:18the editor of Medical Education,
- 06:20defined it as the ability to sort
- 06:23through a cluster of features presented
- 06:26by a patient and the sign a diagnostic
- 06:29label with the development of
- 06:31appropriate treatment as our end goal.
- 06:35Now when it comes to clinical
- 06:37reasoning theories,
- 06:37there are so many frameworks
- 06:39that inform what we teach,
- 06:40often drawn from other sciences,
- 06:43particularly the cognitive science
- 06:46realm and cognitive psychology,
- 06:49to maybe even a little bit
- 06:50from business as well.
- 06:52I don't know if any of
- 06:53these are familiar to you,
- 06:54but it's just so I can give
- 06:57a broad strokes on them.
- 06:58The deliberate practice,
- 07:00just the importance of doing effortful,
- 07:03meaningful practice with getting
- 07:05reps around your around clinical
- 07:09reasoning in different settings,
- 07:11knowledge organization,
- 07:12both frameworks and approaches
- 07:14to your cases and also how you
- 07:18store that information yourself.
- 07:19The term illness script has become
- 07:22really popular and we've recently
- 07:24developed a framework called the
- 07:26management script of how you organize
- 07:28information about diagnosis and
- 07:30management options in that given patient.
- 07:33In addition to that,
- 07:36sorry about quick Trigger on
- 07:38my mouse dual process theory,
- 07:40the idea of thinking fast and slow
- 07:43might be familiar to y'all so thinking fast,
- 07:46so system.
- 07:47So this is popularized by Daniel Kahneman
- 07:49who won actually a Nobel Prize for this work.
- 07:51He was actually getting
- 07:52economics I want to say,
- 07:54but system one being pattern recognition,
- 07:57which is what our more seasoned experts use,
- 08:00versus system 2 which is our
- 08:02more analytical thinking.
- 08:03But it's much more time consuming and
- 08:06eventually over time learners move
- 08:08more from System 2 to system one.
- 08:10And then finally,
- 08:12probably the biggest theory that's
- 08:14gaining traction in the clinical
- 08:16reasoning literature is around situativity.
- 08:18So what's going on in the environment
- 08:20knowing that clinical reasoning
- 08:21isn't just practice inside the head,
- 08:24that it's practice in an environment
- 08:26that changes,
- 08:27that involves many different partners,
- 08:29including the patients involved
- 08:31in their care.
- 08:32And they're even subcategories
- 08:33of this that I won't believe.
- 08:35But just the idea of context is
- 08:38important in clinical reason.
- 08:40So if I had to break down a cognitive
- 08:42model and it's really started to
- 08:44become more solidified over the past,
- 08:47I want to say like 7 to 10 years.
- 08:50There are 4 main steps in the
- 08:53clinical reasoning process that can
- 08:54be like ordered in different ways,
- 08:56but those steps are data collection.
- 09:00So how your learners get information,
- 09:02all of these will derive from the
- 09:04the definition that I gave a clinical
- 09:07reasoning problem representation.
- 09:08So how you synthesize that information,
- 09:11how do you determine signal from
- 09:13noise sick or not sick.
- 09:15We usually see that in the one liner
- 09:18that assessment that we think about,
- 09:20you know the part where we as
- 09:22attending is actually like perk
- 09:23up and listen a little bit more
- 09:25closely to our learner.
- 09:26Next prioritizing A differential diagnosis,
- 09:29obviously what we think of
- 09:31most with clinical reasoning.
- 09:32If I could break it down just into two steps,
- 09:34a little bit more, I would say one,
- 09:36just coming up with a list of diagnosis.
- 09:39This is what we usually see our more
- 09:42junior learner struggle with the
- 09:45right like your medical PA students.
- 09:47Whereas when you get to more senior learners,
- 09:50it's more about how do they decide
- 09:52which of those diagnosis files,
- 09:54those illness scripts, should they choose,
- 09:56which one matches more to this diagnosis.
- 10:00And that's where,
- 10:01you know they can decide on what
- 10:02eventually they need to do,
- 10:04which is the next step of management
- 10:06reasoning and break this down into
- 10:08two components, management scripts,
- 10:10how do you decide what your options are?
- 10:14And then finally,
- 10:15testing and treatment thresholds,
- 10:16whether or not to do something at all.
- 10:19So with those 4 broad steps,
- 10:21I want to think about how we assess
- 10:23our learners and teach our learners.
- 10:25But before I do,
- 10:27did anybody have any questions
- 10:29about this so far?
- 10:33All right. Last thing I'll just
- 10:36say about this is that this model,
- 10:38so to speak, of clinical
- 10:40reasoning is constantly happening.
- 10:42The process of clinical
- 10:44reasoning is iterative.
- 10:45And that's actually the best process, right,
- 10:47Because we know there's so much uncertainty.
- 10:49We know that there's so much new information
- 10:52that even as you're taking a history,
- 10:53you know that your differential
- 10:55is changing literally word to word
- 10:57by what our learners are saying.
- 10:59So with that in mind,
- 11:00how can we assess clinical reasoning?
- 11:03All right, so warm y'all up a little bit,
- 11:05everybody's gotten a chance to eat.
- 11:06This is where I asked for some audience
- 11:09participation, even if cameras are off.
- 11:11That's OK.
- 11:12And I was wondering for y'all,
- 11:16how do you identify?
- 11:18If your learner is struggling
- 11:20with clinical reasoning,
- 11:21feel free to put it in the chat
- 11:23or unmute yourself and share.
- 11:42know your learner struggling
- 11:43with clinical reason
- 11:47for you guys who might not have microphones,
- 11:49Feel free to put it in the chat too,
- 11:53right? Melissa said. Doesn't
- 11:55formulate an appropriate differential.
- 11:56Yeah, that's like kind of like the
- 12:00the the stop as far as like oh wow,
- 12:02like now you need to say what
- 12:04you think is going on and you're
- 12:06not just presenting information.
- 12:08Definitely. For sure.
- 12:08The differential is a great
- 12:09place to diagnose,
- 12:15telling you you can't even summarize that.
- 12:18You know, Kind of like the assessment
- 12:21where it's just like a whole bunch of
- 12:24facts kind of put together, all hodgepodge.
- 12:27Yes, for sure, right when they are
- 12:30really struggling to like collect
- 12:32or all that information to what
- 12:34what matters most, right Penina.
- 12:36And really determining
- 12:37that can be challenging.
- 12:39So at least for each of these steps,
- 12:40here are some broad ways
- 12:42that I understand a patient,
- 12:44when you're listening to our
- 12:45presentations that you can kind of
- 12:47like tune into where you might be
- 12:48able to teach your learners the most.
- 12:50So first is for data collection.
- 12:53The quality of the information is very good.
- 12:56It's not clear.
- 12:58It's missing information.
- 12:59And that's the gestalt.
- 13:00That's when you're like,
- 13:01you wasn't attending,
- 13:02you're like, wait, wait,
- 13:03what's going on with this patient?
- 13:05That's usually a sign that your learner
- 13:08hasn't gotten enough information.
- 13:10Next up, problem representation,
- 13:11like Panino was mentioning,
- 13:12most seen in the assessment,
- 13:14also in sign outs.
- 13:15That's a great time to figure out or
- 13:17in consults hearing like a learner
- 13:19summarize that information and they
- 13:20just can't put that information together.
- 13:22They're not including the right stuff.
- 13:24It's disorganized and all over the place.
- 13:27It doesn't really give a tempo,
- 13:29a timing of how the patient
- 13:32might be evolving,
- 13:33prioritizing A differential diagnosis.
- 13:35So obvious, like we said,
- 13:37either there's not enough diagnosis and
- 13:39they're not really in a reasonable order.
- 13:41And I will say this about honestly,
- 13:43this goes for clinical reasoning,
- 13:45but specifically for
- 13:47prioritizing differential,
- 13:48we're not looking for a
- 13:50single correct answer.
- 13:51There's so many analogies.
- 13:53I'll I'll use some related to like sports,
- 13:55for example, a strike zone,
- 13:57especially because we're like
- 13:59baseball season right now,
- 14:00but we're not expecting it to
- 14:02be in a single place,
- 14:03right.
- 14:03It could be around a general area
- 14:05for a differential for a learner's
- 14:08clinical reasoning to be fairly strong,
- 14:10but we're looking at to be for it to
- 14:13be somewhere around there management
- 14:15even more so actually in management
- 14:18there often isn't a right answer and
- 14:22the the answer changes right over time.
- 14:24So some signs of this can be a
- 14:26little bit more it can be either
- 14:28like very blunt and obvious right.
- 14:30The plan is incomplete.
- 14:32There's very clear evidence based
- 14:34guideline interventions that are not
- 14:37being like suggested recommended ordered.
- 14:39But then there are like more like faint
- 14:42signs that I'll notice particularly
- 14:44in higher stakes such situations.
- 14:46I attended our step down
- 14:48unit not infrequently,
- 14:49so I'll notice here some things
- 14:53like indecisiveness which might
- 14:55suggest that a learner has
- 14:56doesn't have really well honed
- 14:58testing and treatment thresholds.
- 14:59It's great to like have
- 15:01uncertainty and acknowledge that,
- 15:03but you got to know what you want
- 15:05to do with that uncertainty over
- 15:06testing under treatment that my
- 15:08high value care colleagues will
- 15:09certainly want me to recommend that.
- 15:11I include that in in management
- 15:14reasoning too.
- 15:15And there's a ton of overlap as well.
- 15:16There's our patient care
- 15:18communication aspects around the plan,
- 15:20but those are some general impressions
- 15:22of what you're looking at for when a
- 15:25learner might be struggling in those
- 15:27areas. All right,
- 15:28I'm gonna think about some.
- 15:30I'm gonna share some strategies,
- 15:32both generally about teaching
- 15:34clinical reasoning and specific
- 15:36with the niche strategy.
- 15:38But I'm gonna pause again.
- 15:40I'm putting myself out there to
- 15:42everybody to ask what are some ways that
- 15:44you like to teach clinical reasoning?
- 15:46It could be anything,
- 15:48a very broad open-ended when you
- 15:51like teaching how you like teaching.
- 15:54Whatever comes to mind,
- 16:11Richard, that you're unmuted.
- 16:12Did you want to say something?
- 16:14Yeah, I was. I mean it's more
- 16:16I guess relevant in cardiology,
- 16:19but I like to usually point them
- 16:22towards thinking the Physiology of
- 16:24what we are talking about and then
- 16:26have that drive towards, you know,
- 16:28what you're going to do for the patient.
- 16:30That's great. And it's Rushka,
- 16:32right, that I, I, I love that.
- 16:35And that's really good for learners,
- 16:38especially when they're newish
- 16:40to a field as well, right?
- 16:42Especially so your,
- 16:44your clerkship learners,
- 16:45they have that basic and science knowledge.
- 16:46So that's actually kind of fun and
- 16:49reinforcing for them to see like oh wow,
- 16:50like I know something or
- 16:52you're like early fellows.
- 16:54I'd imagine they're still like really wrote,
- 16:57you know, close to that,
- 16:58like that Physiology,
- 17:00although I imagine this specialty,
- 17:02you're always close to your Physiology,
- 17:04but tying that back that can
- 17:06connect it ground alertness,
- 17:07clinical reasoning and and almost
- 17:09act as a framework too for different
- 17:11options of possibilities, right?
- 17:13Like a patient might have an
- 17:15AKI and you can say like,
- 17:16OK, what are like the parts?
- 17:18Like let's follow like the urine
- 17:19all the way to like the ureters,
- 17:21right?
- 17:21Like,
- 17:22So what are the areas where a lesion
- 17:24could occur to 'cause this AKI?
- 17:41So using Physiology,
- 17:42that's a that's a great way
- 17:43to teach clinical reasoning.
- 17:45Anything else?
- 17:46Maybe one more strategy.
- 17:48I'll wait for
- 17:50quiet one day group, everyone
- 17:55or a clinic without a audio
- 18:00Penina. What's that? What's
- 18:01the strategy for you to teach?
- 18:02Yeah. I would just say I I
- 18:05feel like a four year old or a
- 18:08three-year old or always say why.
- 18:11Yeah, you know, it's like not
- 18:14just regurgitation, but OK,
- 18:17Why, why did you say that?
- 18:19What were your thoughts?
- 18:22Or else asking like the learner
- 18:25just didn't explain their reasoning
- 18:27versus just giving an answer
- 18:29that is amazing.
- 18:30And that's, are you going to be
- 18:32the first one that I say for Nina?
- 18:35So First off is just clarification, right?
- 18:38Like, what were you thinking behind that,
- 18:41right, Like because we know from
- 18:43multiple choice questions, right,
- 18:44that like an answer doesn't
- 18:46necessarily show what's going on.
- 18:47So just asking them to clarify
- 18:49in different ways, right?
- 18:50That could be like saying why
- 18:52watching them do an exam or watching
- 18:55them ask like those questions.
- 18:56So getting primary information
- 18:58arguably is the most important,
- 19:00though the most time consuming as well.
- 19:03So you know,
- 19:04important to note in certain
- 19:06situations scaffold.
- 19:07So this goes to what Carol was mentioning
- 19:09and also Urgeka to a degree as well, right?
- 19:13So for frameworks, frameworks,
- 19:14frameworks is the name of the game.
- 19:16In teaching clinical reasoning,
- 19:17we simply to go back to deliberate practice.
- 19:20We don't get like our 10,000 hours anymore
- 19:24in clinical practice to really have like
- 19:27exemplars for every single situation.
- 19:29So giving your learners ways to identify and
- 19:32figure out what's going on in a patient,
- 19:35even if they haven't seen it before,
- 19:37can be helpful.
- 19:38And so common ones are just
- 19:41by organ system anatomy.
- 19:43Some could be like processed like vascular,
- 19:47neoplastic, infectious, inflammatory,
- 19:51or even something such as simple as
- 19:54what's a must not misdiagnosis for this,
- 19:56what's common even like, you know,
- 19:57remove like some like data.
- 19:59Just thinking about this cheap
- 20:01concern and don't narrow too soon.
- 20:03Frameworks is a way to really
- 20:05teach clinical reasoning modeling.
- 20:07So this is one way I wanted to say
- 20:09you're allowed to do this as faculty.
- 20:11This is literally the main feedback
- 20:13that I got for my first two to three
- 20:15years as an attending on my emails.
- 20:17Doctor W,
- 20:18It's nice that you say that
- 20:20that was a reasonable plan,
- 20:21but we'd really want to
- 20:23hear what your thinking is.
- 20:24And so clarifying why like
- 20:26you wanted to make a decision,
- 20:28what was it about this patient
- 20:30or this intervention that made
- 20:32you want to do it or not.
- 20:33And that can actually be
- 20:34really quick as well,
- 20:35because Panino has mentioned that I
- 20:37I know a lot of y'all are in clinic
- 20:39and in the outpatient setting,
- 20:41you're like moving fast and might not
- 20:42have as much flexibility for teaching.
- 20:44So even some quick modelling can be helpful.
- 20:48And then this is one that I after
- 20:50doing a lot of these workshops with
- 20:53students that they asked me to put in,
- 20:56is helping them do some independent learning.
- 20:59Because you can imagine when
- 21:00it comes to clinical reasoning,
- 21:01there are so many different points of
- 21:04a case that learners can grow from,
- 21:06but that can be really overwhelming too.
- 21:09So specifically saying, like, hey,
- 21:12we saw a lot of patients today,
- 21:13but could you look up cystic fibrosis
- 21:16and make an illness script and
- 21:18talk about it tomorrow, right.
- 21:19Or could you look into the trilogy
- 21:22of flow and we can talk about
- 21:24different management options as well,
- 21:26right. And and make it really more.
- 21:29And sometimes what I'll even do is
- 21:31like you have no more than 10 minutes
- 21:33to look this up because that can
- 21:35often give just a sense of relief with
- 21:38all the things that they need to do.
- 21:39So anyway, those are some broad categories
- 21:41as you can imagine for each of those steps.
- 21:44There are examples for this.
- 21:46If I had to give data collection
- 21:49the biggest things that I do when
- 21:52I'm teaching clinical reasoning in
- 21:54the clinical setting on the words,
- 21:57for me
- 22:00it's tough. I don't get a chance to
- 22:02like observe as much as I would want to.
- 22:04I think that's particularly
- 22:06important for more junilers.
- 22:07But when I go back bedside,
- 22:10I'll try my best to like model
- 22:12some specific maneuvers for them,
- 22:13spelled NEUVERS, missing any there.
- 22:16But also I might provide some
- 22:18like additional resources.
- 22:20There are great ones.
- 22:21The Stanford 25 is an excellent one.
- 22:23Rational Clinical Examiner is another
- 22:24one which also I think has a few really
- 22:27nice PEDs files as well one on appendices.
- 22:30This particularly comes to
- 22:31mind for teaching strategies.
- 22:35I was around problem representation.
- 22:38So broad categories of like when you're,
- 22:41when you're trying to help your learner
- 22:43distill what's going on with the patient,
- 22:45just asking them who is the patient, again,
- 22:48what matters most about who they are,
- 22:51their comorbidities,
- 22:52their risk factors epidemiologically
- 22:54and what is going on.
- 22:56Focusing on that chief concern,
- 22:58the time course and the two to
- 23:01three symptoms that really help you
- 23:04narrow your differential diagnosis.
- 23:06One thing I will say is it can be
- 23:09helpful to provide your learners
- 23:10a template particularly for the
- 23:12assessment just from being around
- 23:13many different reports and having
- 23:15so many learners having to present.
- 23:17To me,
- 23:17I know it can be really overwhelming
- 23:19to give that one liner.
- 23:21And so this is just a template that we use.
- 23:23It's very mediciney, internal mediciney.
- 23:25But whatever your framework is that
- 23:27you want to help your learners with,
- 23:30just tell them.
- 23:31For example, I remember Jeremy Mueller,
- 23:35who's like one of my favorite
- 23:36educators here at Yale.
- 23:37He he's really big on.
- 23:39Tell me exactly what the like
- 23:41presentation is first and then go after.
- 23:43Right.
- 23:43So like,
- 23:44this is like a cute,
- 23:48this is acute weakness in the
- 23:50setting of like whatever,
- 23:52like symptoms and features are coming right.
- 23:55And that can be or this is like
- 23:57a mono neuropathy,
- 23:58polyneuropathy And having that be
- 23:59the lead and then going from there,
- 24:01just tell your learner so that
- 24:03they Canmore plug and chug their
- 24:05information as opposed to having that
- 24:07like germane load of figuring it out,
- 24:10prioritizing differential,
- 24:10y'all are all pros at all of these,
- 24:13frankly, but definitely for differential.
- 24:14But just so I can tell you this
- 24:16is what I do with these workshops,
- 24:17to be honest,
- 24:18I just like tell the like teachers
- 24:20what they're doing and they're like
- 24:22what's what tools they're already
- 24:24using in their toolbox so they can
- 24:26use them in the future more confidently.
- 24:29But the scaffolds,
- 24:30like we mentioned from Carol earlier,
- 24:33pneumonic schemas can be really
- 24:35good for increasing just the number
- 24:37of diagnosis that are considering.
- 24:39The biggest one I use when I'm
- 24:42on the boards is pivot points.
- 24:44So pivot points means what a part of
- 24:47the case really LED you one way or the other.
- 24:50That's what can be really best
- 24:52modelled and that can really
- 24:54help you discern how fleshed out
- 24:57your learner's illness
- 24:58scripts are. And for independent learning.
- 25:00There are a bunch of resources here as well.
- 25:04For example, one that I feel like
- 25:06there's a Pediatrics podcast I heard
- 25:07about recently that's really good.
- 25:09I think it's called the Crib Ciders as well,
- 25:12but a lot of fun resources to help your
- 25:14learners learn really easily. All right.
- 25:18Teaching strategies for management.
- 25:20Again, this is my area where
- 25:22I get really jazzed up.
- 25:23But the teaching strategies that I think
- 25:26of most when it comes to management
- 25:29is providing a management script,
- 25:32even if it's suggesting what
- 25:34general categories you can think of.
- 25:36So for example, like today,
- 25:39this morning I was rounding with my res
- 25:40and we were really stuck on a patient.
- 25:42So I was like, all right,
- 25:42like what else can we do?
- 25:44Can you think of any labs imagings,
- 25:46do we need help,
- 25:47do we need to call somebody or monitoring?
- 25:50Is there any way we can follow up
- 25:53information And just that helped us
- 25:54figure out what a few other interventions
- 25:56that we might want it to do as well.
- 25:58I found that's particularly helpful with more
- 26:01with learners on the more like student range.
- 26:06But even early fellows can certainly
- 26:09find help with that specific tier field,
- 26:11the threshold factors.
- 26:13This is when things get really nuanced
- 26:16about why or why not to do something.
- 26:19I'll really work through my
- 26:20learners to say like,
- 26:21what is it about this case,
- 26:23especially when it's tough.
- 26:24When there is that indecisiveness,
- 26:25what is it that matters most?
- 26:27Is it how sick this patient is
- 26:29that's going to determine whether
- 26:30or not we choose antibiotics?
- 26:32Is it just this patient's goals
- 26:33of care when we decide whether or
- 26:36not we want to use chemotherapy,
- 26:37really figuring out what is it
- 26:40that makes us decide one way
- 26:43or the other about a patient.
- 26:46Another thing I'll say because
- 26:47I see a lot of specialists on
- 26:48the call that can be helpful,
- 26:50particularly especially with learners
- 26:52who might not necessarily be on
- 26:55that rotation initially, right?
- 26:57Like you have a general resident on like
- 26:59palm consults like Penina or like you know,
- 27:01a student on cards consults with Ruchika.
- 27:04I think just saying, hey,
- 27:07before you start this rotation,
- 27:09you really need to get down
- 27:11at like like acute cough,
- 27:14right?
- 27:15Or you know narrow complex tachycardia
- 27:18come up with different things to
- 27:21consider at least in a plan before
- 27:24you even start the rotation.
- 27:25I still do that to some degrees
- 27:27before I'm on my rapid response
- 27:28senior before I enter the step down,
- 27:30I'm like alright,
- 27:31like what do I do in acute like hypoxemic
- 27:35respiratory failure or in hypernatremia.
- 27:37When the Ed calls me I'll like give
- 27:39them like some suggestions initially,
- 27:41so giving an initial like framework.
- 27:43So again it makes it more multiple choice.
- 27:46All right.
- 27:48And I have a few more cases,
- 27:49I've talked a bunch.
- 27:50I'm starting to get winded so I'm going
- 27:52to need your help as we go through
- 27:53these as well. I've tried two times,
- 27:55but I I think we're warmed up now
- 27:57to have some more participation.
- 27:58All right, case one, so remember we
- 28:00have our four steps data collection,
- 28:02problem representation,
- 28:04differential diagnosis and management.
- 28:07I'm actually end up with a
- 28:09couple abdominal pain cases.
- 28:10These are from clinic.
- 28:11But I want you all to read over this case.
- 28:15I'll read it as well because I know some of
- 28:18you all are on your phone and in the chat.
- 28:21I want you to tell me which one of those
- 28:24four steps Data problem representation,
- 28:27Differential and management.
- 28:29Where you think this learner is struggling
- 28:31most or where you would consider
- 28:33doing some teaching for this learner.
- 28:35All right,
- 28:36deep breath getting my pretending
- 28:39I'm a resident or student right now.
- 28:42All right,
- 28:42we have a 17 year old girl who
- 28:44reports A few days ago she started
- 28:46experiencing sharp pain localized
- 28:48to her left lower quadrant.
- 28:50The pain rates as intermittent
- 28:51lasts for a few minutes.
- 28:53She's had associated nausea,
- 28:55but decide denies any fever or chills.
- 28:57She doesn't have any past
- 28:59medical history of note.
- 29:01She's a junior in high school and
- 29:03she denies any substance use.
- 29:06Her vital signs were notable
- 29:08for blood pressure 116 / 82,
- 29:10heart rate 80, respiratory rate 18,
- 29:13oxygen saturation 99% on room air.
- 29:16When I saw her, she was uncomfortable.
- 29:19Heart rate was regular, lungs were clear.
- 29:22There is moderate tenderness
- 29:24in that left lower quadrant,
- 29:26but no guarding rigidity,
- 29:29no CVA tenderness and otherwise.
- 29:32Her exam was unremarkable.
- 29:35So I'd say this is a previously
- 29:37healthy 17 year old girl who presents
- 29:39with acute left lower quadrant
- 29:41abdominal pain associated with nausea
- 29:43found to be in moderate distress.
- 29:45Most likely this is caused by a UT I
- 29:48I looked at urinalysis, urine culture,
- 29:51CBC, and maybe start keflex.
- 29:54We could consider an ultrasound or CT,
- 29:56abdomen and pelvis if the symptoms persist,
- 30:00so bear with me.
- 30:01I'm just a humble internist trying
- 30:03to design cases for Pediatrics,
- 30:05but if you got this presentation
- 30:08in clinic regardless of specialty,
- 30:11where do you think this learner
- 30:13is struggling most?
- 30:15Again, feel free to throw it in the chat.
- 30:17Or I mean yourself.
- 30:23Also, So poor Panina doesn't have to
- 30:25keep answering all of the questions right
- 30:27now. Although fantastic educator
- 30:28and we would love to hear from her.
- 30:30Well, I'm bound to be really wrong,
- 30:32so I don't want to embarrass
- 30:34myself. Too bad.
- 30:36Please. That's right.
- 30:37Participation will be can help.
- 30:38Panina. That's right.
- 30:39And me too. I beat it.
- 30:42Where is this learner
- 30:43struggling the most?
- 30:46Can you go back? One slide?
- 30:47Just just a reminder of the
- 30:49four categories. Of course,
- 30:50Of course. There you go.
- 30:53Thank you. All right.
- 30:56Carol puts in differential diagnosis.
- 30:59Catherine puts in data collection.
- 31:02And for what it's worth,
- 31:04all of you know there are
- 31:06so many different options.
- 31:07You could pick any four of these
- 31:09steps and your learner would be like,
- 31:10wow, that's an amazing teacher.
- 31:13But if you want to get your
- 31:15most bang for your buck,
- 31:16I would agree with the chat,
- 31:19Catherine, Carol and Rushka about and
- 31:21Ada about both data collection and
- 31:24differential diagnosis for this case.
- 31:27So going back to this case,
- 31:29so data collection,
- 31:31incomplete history and physical,
- 31:32and there's some strategies
- 31:33that we could do to teach it.
- 31:34But again, so this patient is
- 31:36coming in with abdominal pain,
- 31:38why differential?
- 31:40But you know they they
- 31:42don't mention much about.
- 31:44For example,
- 31:45if this is a UTI,
- 31:46you didn't tell us you you told
- 31:48us that there are any fevers and
- 31:50chills when she's on history.
- 31:52But any dysuria hematuria, right?
- 31:55That'd be nice to know in the physical
- 31:57exam missing just like a temperature,
- 31:59that might be helpful.
- 32:00I'm glad you did a you
- 32:01checked for CPA tenderness.
- 32:03But just information that would
- 32:04be associated with that specific
- 32:06diagnosis and abdominal pain.
- 32:08There's like, you know,
- 32:09plenty of must not miss diagnosis as
- 32:12well to be including in there too, right?
- 32:15Some that are more like GI pathology,
- 32:17some that are even gynecological.
- 32:19Speaking of history,
- 32:21getting more about what is her like
- 32:24sexual history as well would be important.
- 32:26So for those different steps.
- 32:28So First off,
- 32:29for data collection,
- 32:31some teaching strategies that
- 32:32might be helpful.
- 32:33Kind of reinforcing what we talked about
- 32:36before observing their physical exam.
- 32:38Probably not as important in this one,
- 32:41but maybe doing like a hypothesis
- 32:43driven interview.
- 32:44Sometimes I'll literally stop my my,
- 32:47my modeling of interview.
- 32:48Be like now I'm gonna ask my UTI questions,
- 32:51now I'm gonna ask my ovarian torsion
- 32:53questions and it doesn't have to be
- 32:55that quite that prescriptive but
- 32:57even showing them how you would
- 32:59ask specific questions as well.
- 33:01As far as the differential diagnosis,
- 33:03this is obviously very limited.
- 33:04This is an interesting one because
- 33:06we don't know right what the
- 33:08differential diagnosis is right Like
- 33:10we just know what number one was
- 33:12but maybe this learner had other
- 33:13diagnosis they were considering
- 33:15that's when that more open-ended
- 33:17questioning can be really helpful
- 33:19like Penina was mentioning just saying
- 33:21like what else could be going on.
- 33:23No, like UTI,
- 33:24that's should definitely be on the
- 33:26differential but or even numbering
- 33:28like what are two or three more
- 33:30diagnosis that could be going on
- 33:32for with this patient even if
- 33:33you think they're less likely.
- 33:35I'm just so you again you know
- 33:37what their strike zone is.
- 33:39Again for frameworks they're different
- 33:41frameworks that you could provide.
- 33:43This is a way to make it like
- 33:45more multiple choice like I've
- 33:46been saying as well.
- 33:47So maybe they're just struggling
- 33:48to come up with the differential,
- 33:50right.
- 33:50You ask them what else is going on,
- 33:51They just stare at you blankly. OK,
- 33:53Can you think of any other infectious causes?
- 33:57Malignancy causes, vascular causes as well.
- 34:01And there might not be them for
- 34:03every category and you can be
- 34:04judicious about which ones you pick.
- 34:05But that way the learner can also
- 34:07feel more ownership about their
- 34:10clinical reasoning, right?
- 34:11They leave the encounter, feel like,
- 34:12hey, like I did like get some stuff
- 34:14right even though I need to work on it,
- 34:16which can be motivating for
- 34:18them in the future.
- 34:19So great job team.
- 34:21You are right on track as far as data
- 34:25collection and differential concerns.
- 34:27So for case number 2.
- 34:32All right, so this is a patient on the wart.
- 34:36So this is a 17 year old.
- 34:39A female with extra sickle cell
- 34:41disease and exchange transfusion.
- 34:43Twice in the past two years I had one of
- 34:45the Pediatrics fellows give me this case.
- 34:47It makes it way too complicated.
- 34:49I don't know what's going on in this.
- 34:50Anyway, 3 days of fatigue,
- 34:52Lightheadedness and feeling dehydrated.
- 34:54Now with a 2 day history of cough,
- 34:57nausea, vomiting and upper abdominal
- 34:59pain radiating to the left shoulder.
- 35:02She was admitted yesterday to Bridgeport
- 35:04with worsening abdominal shoulder pain.
- 35:06Refractory to Dilaudid PCA.
- 35:09So past medical history.
- 35:12Sickle cell disease.
- 35:13The disease with multiple crises.
- 35:14Baseline hemoglobin of nine Has
- 35:16a history of insulin resistance,
- 35:18had a cholecystectomy previously,
- 35:20Takes ibuprofen and oxycodone
- 35:22for pain but has not filled.
- 35:24Hydroxyurea and metformin smokes marijuana.
- 35:28Daily exam notable for a temperature
- 35:30of 39 four heart rate 107,
- 35:33blood pressure 98 / 65,
- 35:35respiratory over 26,
- 35:37oxygen saturation of 97%,
- 35:41General to Kipnik with mild distress
- 35:46and scleral conjunctural Ichteros
- 35:49diminished breath sounds a sinus
- 35:52tachycardia On cardiac exam.
- 35:54The abdomen was with no organomegaly
- 35:59but diffusely tender.
- 36:00I mean skin was notable for
- 36:02pallor and jaundice.
- 36:03So on labs white blood cell count was 9,
- 36:06hemoglobin 5.7,
- 36:07platelet 77 and neutrophil
- 36:1077% with retic count of 4%.
- 36:13Mild spot was positive,
- 36:14total ability was 6,
- 36:16but the CMP was otherwise normal
- 36:18and there was a normal lipase.
- 36:20So again in assessment we have a 17
- 36:24year old girl with a past medical
- 36:26history of sickle cell anemia
- 36:27who presents with abdominal pain
- 36:29history also notable for fatigue,
- 36:31light headedness and shoulder pain.
- 36:32Most likely secondary to
- 36:35splenic sequestration.
- 36:36As her variant hemoglobinopathy continues
- 36:39leads to continued risk of events.
- 36:41Pneumonia is also possible,
- 36:42giving the fever to get me in tachycardia,
- 36:45less likely pancreatitis.
- 36:47I'd probably give pain medications
- 36:49and start antibiotics.
- 36:51So one thing I think is interesting
- 36:53as I buy time for you all to put
- 36:54this into the chat or feel free to
- 36:56like unmute yourself about what
- 36:57you think is going on with this
- 37:00learner is that often time I do
- 37:04direct observations of faculty
- 37:06and specialties outside of my my
- 37:09area of internal medicine.
- 37:11And I will say while you do have
- 37:13to have a some level of knowledge
- 37:16in these conditions,
- 37:18for the most part I feel like I can
- 37:20get a pretty decent sense of where
- 37:23a learner's clinical reasoning is
- 37:25simply by how they present the information.
- 37:27That's why it can be helpful to
- 37:29have frameworks to some degree.
- 37:30So hopefully,
- 37:31even though this
- 37:37a little bit more specific of a case,
- 37:40y'all might be able to share where you
- 37:41think this learner is struggling the most,
- 37:43even if you might not necessarily know
- 37:46how you would teach it given the feel.
- 37:49So what do you think is
- 37:50going on with this learner?
- 37:52Where are they struggling?
- 37:58Yeah, all four. I agree there's
- 38:02a lot to unpack in this case.
- 38:05One thing I'll I'll say with that in mind,
- 38:07and everybody's different and
- 38:09sometimes you just absolutely need to
- 38:11clarify information from a learner.
- 38:13But I will say usually I'll wait
- 38:15until the end of a presentation
- 38:18before I make any comment,
- 38:19just because there could be so many
- 38:22different things along the way
- 38:23that you might want to talk about.
- 38:25And if you have limited time,
- 38:28sometimes you can only pick
- 38:29like certain specific things.
- 38:38All
- 38:41right, so we have votes for all
- 38:44categories, anything in specific.
- 38:46If you saw this learner what you
- 38:48would consider working with for them?
- 38:52So a couple of things that I would
- 38:54I I feel like would I'd want to
- 38:57work with this learner on one is
- 39:00their problem representation.
- 39:02So this is a very common phenotype of
- 39:05problem representation that we'll get
- 39:06in our learners where they essentially
- 39:08just repeat the history right?
- 39:10How do they distinguish signal from noise?
- 39:12We don't know.
- 39:13And it's like it's really frustrating
- 39:14because it makes the presentations
- 39:16a lot longer.
- 39:17But it is important that they need
- 39:18to find ways to synthesize it, right.
- 39:20And so, you know, sometimes in notes,
- 39:23I like limit learners.
- 39:24I mean, obviously we have like
- 39:26really complex patients sometimes.
- 39:27But all right,
- 39:27you tell me what are like the two or
- 39:30three most important comorbidities we have,
- 39:32All right.
- 39:32Like if you have to pick two symptoms,
- 39:34what would the,
- 39:35what would you include,
- 39:36what are the two labs you would
- 39:37want to or how would you categorize
- 39:39this patient's timing? Right.
- 39:41It's abdominal pain, like is it acute,
- 39:43is it sub acute, chronic, right.
- 39:45Those are whole different
- 39:46differentials for us as well.
- 39:48So that would be one thing for
- 39:51problem representation as well.
- 39:53The other one is management, right?
- 39:56And now to be fair,
- 39:58it's like I don't know how many
- 40:00learners you would have who
- 40:02would actually just say give pain
- 40:03medications and start antibiotics,
- 40:05maybe an early clerk.
- 40:07But still y'all know that there
- 40:09are plenty of times that we need
- 40:11our learners to specify more.
- 40:13And so that's when it can be helpful
- 40:15to give them a prompt like that
- 40:16management script template that I mentioned.
- 40:18Like, OK,
- 40:19you don't have to say everything,
- 40:20but any tests you want to do,
- 40:22any diagnostic tests.
- 40:24Any medications we want to give,
- 40:26when should we follow up with this patient,
- 40:28right or how long do we want to
- 40:30wait until we get the next BMP.
- 40:32So asking for a little bit more clarity
- 40:35around the management can lead to really,
- 40:37really helpful discussions.
- 40:39And honestly,
- 40:40that's one of the biggest parts of
- 40:43our our clinical reasoning on rounds,
- 40:45right is really helping our learners,
- 40:47especially the more senior learners
- 40:49hone their testing and treatment thresholds.
- 40:51For those early learners,
- 40:53it's just figuring out what you could
- 40:55do and for more senior learners
- 40:57it's figuring out why you should
- 40:59do one thing versus the other,
- 41:00knowing that there isn't necessarily
- 41:03a single right answer.
- 41:06So with that in mind,
- 41:07that's a that's a wrap for me.
- 41:09I wanted to give you all some break.
- 41:11I know again that this is a a
- 41:14busy time for Y'all in between,
- 41:15but I'm around for questions.
- 41:17But again to summarize today we talked
- 41:19about a few things in clinical reasoning.
- 41:22One,
- 41:22we talked about why we do this,
- 41:23which is diagnostic error.
- 41:25We gave some language,
- 41:26we talked about some theories as
- 41:29well and really mentioned about the
- 41:31situativity theory, the context.
- 41:33I I probably didn't talk about
- 41:35that as much as we should but you
- 41:36know that
- 41:37clinical reasoning is different
- 41:38in different environments, right,
- 41:39a busy clinic versus having like
- 41:41all the time in the world if you're
- 41:44on like a slow day of rounds.
- 41:46We talked about strategies to assess
- 41:48and teach clinical reasoning really
- 41:49based off of those four steps,
- 41:51data collection, problem representation,
- 41:53differential diagnosis and management,
- 41:55and broad categories of teaching
- 41:57open-ended frameworks, modeling,
- 41:59and providing some directed
- 42:02learning to do afterwards.
- 42:04And then we had a few fun examples,
- 42:07a lot of which I'm not completely sure
- 42:09I knew as a general adult internist.
- 42:13So yeah, sorry,
- 42:13I have some questions here,
- 42:15Feel free to throw them in the chat if
- 42:16or if you are ready to head out as well.
- 42:21I just want to remind everybody
- 42:22what the code is for today.
- 42:24It's 42047 for CME credit,
- 42:29but for Carol, as Carol asks,
- 42:32brings a great point.
- 42:33I don't know if that's a question
- 42:35or just like something we
- 42:36could work on for management,
- 42:38but I think this triage,
- 42:40this disposition is huge actually.
- 42:43So particularly,
- 42:44we know that diagnostic errors happen
- 42:46most in these transitions of care.
- 42:48So really making the decision,
- 42:50can this patient go home?
- 42:51Do they need to go to the Ed?
- 42:53Or if they're in the Ed,
- 42:55should they like, be admitted,
- 42:57Should they go home or should we like wait
- 43:00a little bit longer while they're here?
- 43:02That can be really helpful,
- 43:03particularly to model with our learners
- 43:06to unpacking why that might be so.
- 43:09OK, great.
- 43:12Thanks so much.
- 43:13Sorry, can I
- 43:14ask a great question?
- 43:15So for the four different categories
- 43:17of reasoning that you mentioned,
- 43:19do you feel I almost feel
- 43:21like they are interrelated?
- 43:22For example, if the problem is
- 43:23not and you might have said this,
- 43:25I might have missed the
- 43:26beginning of the talk.
- 43:28But is that is that true?
- 43:29Like how I would think about it?
- 43:31Like I would think like if the if
- 43:33the learner is struggling with
- 43:35the problem representation not
- 43:36he won't he or she won't come
- 43:38up with the right differential
- 43:40and hence that will affect the
- 43:42next steps of management
- 43:44exactly exactly. All of this is intertwined
- 43:46and as we've like developed like the side.
- 43:48So I will admit I'm a splitter and not a
- 43:51lumper and my colleagues and Co researchers
- 43:53in the field feel like differently about it.
- 43:56But I think part of why I do try and split
- 43:59sometimes is because then at least you have
- 44:02a better idea of what you can teach, right?
- 44:05Because then if you're teaching
- 44:06like generally it can just be hard,
- 44:08there can just be so much to cover.
- 44:10But you are absolutely right,
- 44:11like combine the steps right now.
- 44:13Hypothesis driven physical examination,
- 44:15right? You need a differential
- 44:17to know what like to do,
- 44:19what questions to ask.
- 44:21Or for example,
- 44:23people say a problem representation that
- 44:26leads towards a differential diagnosis.
- 44:28They pick specific information, right?
- 44:30Because they want you to think of these
- 44:32diagnosis and I will say in like that model,
- 44:35like a lot of a lot of researchers or
- 44:40like educators will will post it that that
- 44:44hypothesis generation actually is the
- 44:46first step that that's where you start.
- 44:48And from there you have data collection.
- 44:51So obviously,
- 44:52they definitely blend together.
- 44:54But if it can be helpful just to pick
- 44:56like 1 area specifically where you want
- 44:58to focus at least for a given encounter.
- 45:01Does that make sense?
- 45:02Yes. Got it. Yeah,
- 45:03that's what I was trying to like.
- 45:04In my mind, trying to differentiate.
- 45:06It makes sense to pick one to
- 45:07do an intervention in a small
- 45:09session with this with a learner,
- 45:10but OK, thank you.
- 45:14And I will say a lot of you teach medical
- 45:16students or I think they even do this in
- 45:18graduate medical education with the Epas.
- 45:19Like all of these qualities because
- 45:21map out to the Epas as well.
- 45:24Like if you go from like a level 1 to a level
- 45:275 from like pre entrustible to entrustible,
- 45:29if you like read the fine print,
- 45:31they essentially include all of these.
- 45:33They might not say problem
- 45:35representation because that's probably
- 45:36too dense of lingo when they were
- 45:38developing these at the double AMC,
- 45:39but all of these map out to that.
- 45:41But at least it's a little bit easier
- 45:42than saying like I think this learner
- 45:44has a good clinical reasoning or bad
- 45:45or I trust them or I don't at least
- 45:47you can like teach them a little
- 45:48bit more specifically that way.
- 45:52And in terms of promoting hypothesis
- 45:54driven history taking and physical exams,
- 45:57sometimes I think if they're going
- 46:00into a room like an outpatient to see
- 46:02a patient with a certain chief concern
- 46:04like right off the bat, I'll say to them,
- 46:06what are you thinking right now just
- 46:08hearing that age and that chief concern,
- 46:10what are some things you're thinking about?
- 46:13And then that helps them say, oh, OK,
- 46:15well I'm going to go in and you know,
- 46:18just this, you know,
- 46:19ask them questions about this,
- 46:21that or the other because I'm
- 46:22already thinking of that.
- 46:23So that's the other thing
- 46:25that's sometimes is helpful to
- 46:27them. That's great, Carol,
- 46:28and I do that as well.
- 46:30I can't say enough that clinical
- 46:32reasoning is iterative and I don't
- 46:34think it necessarily promotes
- 46:35premature closure and anchoring.
- 46:37In fact, I think if you keep learners
- 46:39broad earlier, it can be helpful.
- 46:40But asking them to start thinking,
- 46:42OK, like what diagnosis he's heading
- 46:43into this patient with shortness
- 46:45of breath do you think about,
- 46:46because then they'll know like, oh,
- 46:48I want to ask questions about PE or
- 46:50want to ask questions about pneumonia.
- 46:53That's great.
- 46:53I love that you do that with your learners.
- 47:08Any other tips and tricks from
- 47:10the group that you want to share
- 47:12stuff that Y'all are doing already,
- 47:14which I'm sure is terrific.
- 47:18All right, well, I'll take my leave.
- 47:19Thank you so much for having me. Panina.
- 47:22Thank you everybody for joining.
- 47:24It was a blast.
- 47:25And feel free to reach out if you ever
- 47:27want to talk about clinical reasoning.
- 47:29It's my favorite thing to do.
- 47:31Thank you so much for joining
- 47:33us in Pediatrics, especially
- 47:34since I know you're on service.
- 47:36So thanks so much.
- 47:37We all really appreciated it.
- 47:40Bye all. Bye.