IM Educators - Clinical Reasoning

Name: IM Educators - Clinical Reasoning
Uploaded: 2022-03-09T17:58:33.563Z
Duration: 58 min 41 s

March 09, 2022

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ID: 7514
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00:00Pick it out, wait, come on,
00:03damn we ready to go yes
00:06awesome. Hey Chris. So again,
00:08I appreciate the warm introduction Dana.
00:11Today we'll be talking about
00:13assessing clinical reasoning
00:15for our I am educator series.
00:17I'm really excited today because
00:19we have some of my favorite people
00:22to talk clinical reasoning with.
00:24So from the University of Michigan,
00:27I feel like I'm announcing a sports
00:29team or something like that, but.
00:31We have Emily AB dollar.
00:33She's an assistant professor in
00:35the section of infectious diseases.
00:37She runs their micro course.
00:39She also runs and helps Co run their
00:42faculty development course and has
00:44written one of my favorite papers
00:46about management reasoning about was
00:49qualitative study in academic medicine,
00:51teasing out generalist and
00:54infectious disease doctors.
00:55Factors that went into their clinical
00:58reasoning around management.
00:59We also have Benjamin Gallagher.
01:01Here Ben is.
01:02One of our core faculty in our
01:04primary care center in our section
01:06of general internal medicine,
01:08he is also has been doing great
01:11work in clinical reasoning.
01:13Here.
01:14Part of our clinical Skills Assessment team,
01:17recently published in the paper in J.
01:19Jim about documentation of clinical research.
01:25And how that translates to clerkships
01:27thereafter also on our team today
01:30we have Doctor Andrew Parsons
01:32from the University of Virginia.
01:34He directs their clinical skills course
01:36and their pre clerkship coaching.
01:38He's also one of their APDS.
01:40Has done a lot of work and publications
01:43outside along the way in management,
01:46reasoning and remediation of
01:47clinical reasoning too.
01:49So we're excited to have him here
01:51and then finally name that you
01:53know very well Doctor Chris Sankey.
01:55He is our associate program director
01:57of our traditional internal
01:59medicine residency program has been
02:01doing fantastic work as far as
02:04incorporating clinical reasoning
02:06into our residency programs,
02:08from revamping report to developing
02:10a new hospitalist firm or will have a
02:14lot of fantastic clinical reasoning
02:17innovations including a cognitive
02:19autopsy procedure that will be doing on
02:22our as following up on our decision making.
02:25And so we're so excited
02:27to have everybody there.
02:28And if you're into Twitter,
02:29we have some handles there along the way.
02:33Alright,
02:34so I'm Dana was mentioning this
02:36a little bit earlier.
02:37We have some zoom tips I'd love
02:39if I could see some faces,
02:41but I know people are eating so
02:42we don't want necessarily see
02:43things in their teeth or people
02:45feel self conscious about that.
02:46I'm muting your microphones as you can,
02:49but when the time comes and there
02:51are plenty of times to come,
02:52I want you to speak up.
02:53I want to hear from you, however, that works.
02:56We can.
02:57There's a raise hand function if you
02:59want to use that under reactions as
03:01part of the communications that we do.
03:03Resume and actually I might ask
03:05Ben if you don't mind just keeping
03:07an eye on the chat,
03:08'cause sometimes that can be
03:10hard to figure out who's raising
03:11their hand at any given time.
03:13Also,
03:13Speaking of chat through
03:14your questions into the chat,
03:16part of the reason why we have such a big
03:19team is I wanted folks here and sharing
03:21their clinical reasoning expertise and
03:24answering any questions that you have.
03:26As you can see, we have a wide spectrum
03:28of outpatient versus inpatient providers,
03:31or in addition to that,
03:32specialist two with Emily as well.
03:34So we're here to have a clinical reasoning
03:38conversation more than anything else.
03:40So what are we talking about today?
03:42So our learning objectives and our overview.
03:45We're going to review diagnostic
03:47error and core clinical
03:49reasoning assessment terminology.
03:51We're going to practice assessing
03:53clinical reasoning and various
03:54levels and settings of learners,
03:56and we're going to brainstorm a strategies
03:59for teaching clinical reasoning.
04:01So let's get started.
04:02So why do we do this?
04:03The main reason why clinical reasoning
04:05has gotten so much press lately
04:07is because of diagnostic error,
04:09a topic that our department knows very well.
04:12So the numbers can range.
04:15Generally,
04:15what's quoted is diagnostic errors
04:17occur in 10 to 15% of patient
04:20encounters more in the cognitive
04:22specialties like internal medicine,
04:24less in the perceptual
04:26procedural specialties.
04:27More if you're talking
04:29about diagnostic errors.
04:30Broadly,
04:30even the ones that don't cause harm
04:33may be a little bit less closer to
04:361% as far as severe adverse events,
04:39but regardless, they cause a lot of harm.
04:42Impact on multiple different levels.
04:44And when we've looked back on their errors,
04:47a good chunk of them are cognitive
04:49in some fashion.
04:50And what do we think of when it
04:52comes to cognitive diagnostic error?
04:54We think about clinical reasoning,
04:56and it's not just in the clinical
04:59setting by attendings,
05:00but it's also with our learners students
05:03when it comes to clinical reasoning
05:05on the I am internal medicine clerkships.
05:07This is numbers 123 along with
05:10professionalism and ownership of
05:12patients about what clerkship directors.
05:15And what our faculty are valuing the most.
05:19So I appreciate your being here on
05:21this call to hopefully help you as
05:23you're evaluating your learners when
05:25it comes to clinical reasoning.
05:27Now,
05:28clinical reasoning can be defined
05:30in so many ways.
05:31In fact,
05:32they've been keepers where experts
05:34have regularly disagreed about
05:36that things from problem solving
05:37to judgment to decision making.
05:39My favorite definition,
05:40just as it lends towards what models
05:43I'm going to provide in the future,
05:45are.
05:45Is the ability to sort through a
05:48cluster of features presented by
05:50a patient and accurately assign a
05:53diagnostic label with the development
05:55of an appropriate treatment as the end goal.
05:58Now there are other reasons why we
06:01want to assess clinical reasoning,
06:03but we talked about our two big ones,
06:05diagnostic air and grading it had can
06:08happen in any learner that we're evaluating.
06:11It could be students, residents,
06:14fellows in various settings.
06:16Two right?
06:17So I already touched on this.
06:18We'll be focusing primarily
06:20on the in vivo assessment,
06:22so in related to patients,
06:24either in inpatient or outpatient setting.
06:26But clinical reasoning can be
06:28evaluated in other ways too,
06:30with various levels of fidelity.
06:33Michelle Daniel had a wonderful
06:34review on this a couple
06:36years ago in academic medicine.
06:37Things like multiple choice questions,
06:39particularly because medical knowledge is
06:41really tough to tease out from the decision
06:45making and clinical reasoning process.
06:47Oski's oral exams or other examples.
06:50Things like key features,
06:52script concordance tests.
06:53There are many other things,
06:55but those are probably the three
06:57highlights that are in classroom
06:59evaluations of clinical reasoning.
07:01When honestly anytime we talk about
07:03a patient is when we can think
07:06about clinical reasoning and assess
07:08it in our learners.
07:10In the inpatient setting that could be
07:12on rounds during sign out during triage,
07:15for example.
07:15When I'm in the step down unit that.
07:17Ability to triage a patient,
07:19how sick or not they are,
07:21or a fellow Triage Ng console calls.
07:23For example, we can evaluate in
07:25our notes chart stimulated recall,
07:27which we won't necessarily
07:29be focusing on here.
07:30We'll kind of be inferring our
07:33chart evaluations of clinical
07:35reasoning and the outpatient setting.
07:37Again, it can be even quicker,
07:38actually,
07:38sometimes right when you're
07:40staffing patients in clinic.
07:41And of course notes is a great place
07:44in both inpatient and outpatient
07:46to evaluate clinical reasoning.
07:49So how do we do it now?
07:52There are various different
07:54models of clinical reasoning,
07:55but this is these are generally
07:57the steps that we think of when
07:59it comes to going through that
08:01clinical reasoning process.
08:03First off,
08:04is collecting data you talked to any
08:06cognitive psychologist clinician educator?
08:09They'll tell you that good data
08:11is the most important part of
08:12the clinical reasoning process.
08:14So history, physical examination,
08:16collecting that laboratory data,
08:18looking into the chart.
08:20And getting the information that
08:22you need to problem representation.
08:24So that's just how you synthesize
08:26that information.
08:27So putting it into your Google
08:30search engine of your mind and the
08:33various diagnosis that you know,
08:35prioritizing that differential,
08:36the step that we most commonly
08:38think about with clinical reasoning,
08:40so both coming up with hypothesis and
08:44selecting which one so an illness script,
08:47which is something that each
08:48of us have for a diagnosis.
08:50That's just our mental file on a condition.
08:53Who gets it? The epidemiology?
08:55Why they get it,
08:57the pathophysiology,
08:58and how they get the clinical features,
09:00the signs,
09:01symptoms and diagnostics related to that.
09:04Finally management.
09:05Which we break down into smaller steps,
09:08including management scripts just
09:10coming up with what management
09:13options you can do and thresholds.
09:15What point Are you ready to do?
09:17That is a red light yellow
09:19light or green light?
09:20Is it not doing an intervention testing for
09:23a possible diagnosis or actually treating it?
09:27Now this process keeps going and
09:29there are different times within
09:31that process that it starts.
09:33For example,
09:33this is from one of Andrew's papers
09:35on remediation of clinical reasoning
09:37where a lot of times we can honestly
09:41start the diagnostic process.
09:42When we begin right,
09:43we generate hypothesis and that's that
09:46affects how we ask our questions right?
09:48Which leads to a problem
09:50representations and then new hypothesis,
09:51and so I don't want to make it
09:53seem like it's necessarily rigid.
09:54It's an iterative process
09:56that you're entering at.
09:57Any given time in the diagnostic
10:00process for patient encounter.
10:02So those are some core steps
10:04as hopefully we've moved on
10:06to getting some case action
10:08which should hopefully be fun.
10:10And now I wanted to practice
10:12assessing clinical reasoning
10:13with some different models,
10:15including that one we just talked about.
10:17So Andrew, I wanted to talk a
10:19little bit about how you identify
10:22clinical reasoning struggles.
10:23So let's start off with data collection.
10:26How do you know that a learner is
10:28struggling with data collection?
10:31Sure, thanks a lot.
10:32So just like you displayed
10:33that that cognitive model and
10:35you have it up again here,
10:37I think my approach is to have that
10:40framework in place and then through
10:42a number of case based assessments,
10:45try to try to pull out some
10:48patterns of behavior that the
10:51learner is is presenting and then
10:53target in to one of these specific
10:56cognitive processes to say yes,
10:59they're struggling with
11:00clinical reasoning but which?
11:02Area along this this step by step process,
11:05are they struggling most and of
11:07course context is critical here,
11:09so it it's you don't want to
11:11make too many assumptions based
11:12on one oral presentation or one
11:15note or one patient encounter,
11:17but the the more you can accrue the better.
11:21But with data collection,
11:22it's always as you're presenting to me,
11:25or as I'm reading through your note,
11:27are you collecting the high yield
11:29data in a somewhat organized process,
11:31and I think we've all been
11:33there as assessors.
11:33Can we can we kind of,
11:36you know,
11:36see into your mind and in your thought
11:38processes as you're presenting data to me.
11:41So somebody that's struggling
11:42in this area as it says here,
11:44would would their presentations might
11:46lack clear information or high yield data.
11:49What
11:50about problem our presentations?
11:52So problem representations I think
11:54of in two ways in terms of struggles,
11:56they can lack structure,
11:58which we'll talk about later.
11:59They can lack a standard scaffolding
12:01that speaks more to perhaps a
12:04communication issue more than anything.
12:06But if you look into which data is included,
12:10and again, there's,
12:10there's some overlap here
12:12with data collection, right?
12:13How have you taken those high yield things?
12:15Those high yield features of the case,
12:18and included them in a single
12:20summary statement that will allow
12:22you to move towards the next step.
12:24Of refining your your broad
12:27differential diagnosis down to
12:28just a few prioritized diagnosis.
12:34So when it comes to prioritizing
12:35a differential, there are so many
12:37ways that we can see this right,
12:38Andrew? So what like really,
12:40are you noticing when a learner is
12:43presenting to you in whatever fashion?
12:46Yeah, I think of this on the two extremes,
12:48right? You're either 2 prioritized,
12:51meaning you've prematurely
12:52closed in on on a diagnosis,
12:54and so you're struggling too.
12:57You know, justify inclusion of other
13:00diagnosis or you're engaging in what
13:02we call some call siloed diagnosis,
13:03which is you can't narrow down.
13:06So the broad differential you
13:07started with kind of carries forward,
13:10despite you picking up other pieces of
13:12data that that should push you to narrow
13:14it and so you end up and you know.
13:17Again, this always flows to the next step.
13:19You end up saying, well,
13:20let's test for this.
13:21Let's test for this.
13:22Let's test for this because you're unable
13:24to prioritize it down any further.
13:27And as management reasoning
13:28high value care is your jam,
13:30I know what about management
13:32that really like stands out in
13:34a learning struggling there.
13:36Yeah, I did get. I think of this one
13:38in in two ways as well and we'll
13:40talk about management scripts later.
13:41But you know, for the given working diagnosis
13:45that you that you've presented have you
13:48thought through a basic management plan?
13:51Whether that's monitoring,
13:52treatment labs, imaging, whatever,
13:54it may be specific to that diagnosis
13:57that step one and then also how have
14:00you pick and how have you taken things
14:02out of that kind of management menu?
14:04Purcella and applied them to the patient.
14:06And that's where the high
14:08value care comes in.
14:09So yeah, if they're not doing this well,
14:11you might see an inappropriate plan,
14:13inappropriate either for the
14:14diagnosis or for the patient.
14:16It can be indecisive or over testing
14:18and treatment like we just mentioned.
14:20Awesome thanks, Andrew,
14:21and feel free once again to throw
14:23questions in the chat or raise your hand
14:26will keep an eye on that so we can.
14:28We can answer your questions as they come up.
14:31I'll also say this model is if
14:33you're looking for resources and
14:35I'll throw them in the chat as well.
14:37Actually, I'll do that right now.
14:40There's this is a Google Drive link to
14:42our tip sheet that we give all instructors
14:44in our clinical reasoning course.
14:46The system assessment of reasoning
14:48tool so size society to improve
14:50diagnosis in medicine which actually
14:53helped Commission or was commissioned
14:55by the National Academy of Medicine
14:57in that big report on improving
14:59diagnosis and health care,
15:01developed their own assessment of reasoning
15:02tool which got at some of these same test.
15:05There are some really slick
15:06videos that they have.
15:07About how you can better assess clinical
15:10reasoning related to these steps,
15:11they also added the step of metacognition,
15:14which just means having reflective,
15:16thoughtful learners and then more
15:19specifically the idea of cognitive biases.
15:21Although we haven't seen that really
15:23show up well as far as teaching
15:25towards it in the literature,
15:26there is even an assessment tool so
15:29the assessment reasoning tool I'm
15:30sorry I mean more about a worksheet
15:32on how you can potentially evaluate
15:34your learners which goes along
15:36the lines of you know.
15:37From minimal to complete,
15:39as far as how your learner is doing
15:41when it comes to a set for your
15:43assessing their various steps within
15:46the clinical reasoning process.
15:48So with those in mind,
15:49let's get to some practice cases alright,
15:52and that way I can also get
15:54some of these polls going too,
15:56so we're gonna have a Ben hop on and talk
15:59a little bit about a an outpatient case,
16:03but I want everybody to put
16:04their thing cats on,
16:05so imagine you're in clinic
16:07in turn is presenting to you,
16:09and this is just,
16:10you know,
16:10they saw a patient there staffing
16:12it with you now and the situation is
16:15they're presenting a mileage woman.
16:17Who has anemia of possibly gastrointestinal,
16:22organic logical etiologies?
16:24And you're trying to both actually
16:27hear what's going on with the patient,
16:30but also to.
16:34Diagnose your learner as well,
16:36which I always remember.
16:37It was just so tough to do when I was
16:40in the outpatient setting and teaching.
16:41So I'm gonna play the patient
16:43presenting to Ben and T all.
16:45And why don't y'all think about
16:47what's going on with this patient?
16:50So we have a.
16:51So yeah, Doctor Gallagher,
16:53we have a 52 year old lawyer who comes
16:55into clinic after being found with
16:57hemoglobin over 8 1/2 on routine blood work.
16:59She's over the past year
17:01been increasingly pale,
17:03weak and short of breath.
17:04She doesn't have any significant bleeding,
17:07though.
17:08She notes that she occasionally
17:09have flecks of blood when wiping
17:11after bowel movements,
17:12which she's attributed to hemorrhoids.
17:14She notes that her menstrual
17:15cycles are a little bit
17:16more regular, lasting anywhere from 2
17:18to 8 weeks, with much heavier periods
17:21that have lasted about 10 days.
17:22Lately I'd help with the discomfort she's
17:25been taking some ibuprofen as needed.
17:27That said, she's up to date with
17:28her mammograms and Pap smears,
17:29though she's never had a colonoscopy.
17:32Hospital history is notable for
17:35hypothyroidism. No surgery.
17:36She's on levothyroxine.
17:37She lives in the Camden,
17:39does have a history of smoking
17:4140 pack years on exam.
17:43She's looking relatively OK.
17:46I mean, she does seem weak,
17:48but her vitals are normal.
17:50She is pale conjunctive a cardiac.
17:52I'm exam is regular and she's
17:55clear to auscultation.
17:57Her extremities are a little
17:58bit cool and her skin is pale,
18:00but nothing else that really stands out.
18:03So on assessment and plan,
18:05we have a 50 year old woman with a
18:07past medical history of hypothyroidism
18:09and hemorrhoids who presents with
18:11anemia in the setting of pallor,
18:13weakness, fatigue,
18:14and bloody bowel movements.
18:16Most likely is hemorrhoids,
18:18for which I recommend doing
18:20a rectal exam and an OSCA P.
18:23In addition to rechecking H&amp;H for a week,
18:26if we really wanted to,
18:28and she pushed for it,
18:29we could consider a GI console
18:31and a colonoscopy.
18:32So I'm launching a poll.
18:34I'm going to give some time for the
18:3635 or so on of y'all on the call for
18:39you to pick which areas where you
18:42think this learner is struggling.
18:44I made this multiple choice because
18:46I know with our learners right there
18:49can be multiple things going on.
18:51As y'all are doing that, I'm going to.
18:54We get some access to our document,
18:58but alright.
19:05Alright, so we have 12 people right now.
19:08I think we can get up to 25
19:10of the 35 people here 20.
19:20Alright, and what I will say about this
19:23is more people are filling out the polls
19:25for only a 20 who participated so far.
19:27Is that multiple things could be going
19:29on in the clinical reasoning process,
19:32but I'll also say that you know,
19:35oftentimes, like if there's a clinical
19:38reasoning shortcoming earlier on,
19:40it'll affect everything downstream,
19:41so I appreciate your suspending
19:44your disbelief in this process.
19:46Awesome, we're at 2526.
19:48Dana, we're getting such great
19:50participation right now and I'll say that
19:52it looks like the group thinks that this
19:55learner is struggling across the board.
19:57But particularly with prioritizing and
20:00differential diagnosis and management.
20:01So Ben, what do you?
20:05How would you approach this
20:07learner as our faculty did?
20:09Who also thought they the learner were
20:11struggling with prioritizing a differential?
20:13Yeah, I think this is a really.
20:16Interesting case,
20:16I think I'll say first that.
20:19In the outpatient world with,
20:21you know my students and medical
20:23residents and other learners.
20:24I think it differs from the context
20:28that a lot of our learners are
20:30used to being in the inpatient
20:32world in terms of both the problems
20:34that they're dealing with.
20:35Kind of the the way that you can kind
20:37that you the sort of the scope of the
20:39problems that are potentially could be
20:41brought up at any visit that appear,
20:43especially in primary care.
20:44Theoretically,
20:44anything you know could be could be on the
20:46table for something for you to address,
20:48and then both of the.
20:49Urgency of of the evaluation and
20:52diagnostically and therapeutically.
20:53And you know how readily available
20:57at different diagnostic and
20:58therapeutic interventions are to all
21:00of that is is pretty different now.
21:02I think even starting from just how.
21:06At the expected organization of
21:07an oral presentation or a note,
21:09I think we have a pretty good shared
21:12understanding of what that should look like.
21:14On the immigration rules,
21:15and that's kind of how you know
21:17students and other learners are
21:18taught on the outpatient side.
21:19I think as much less of a consensus
21:22about about how a note should be
21:24presented and how a case should be presented.
21:27This one.
21:27Fortunately, that was a pretty,
21:29you know, this sort of problem based
21:30and and it is a as a, you know, uh?
21:33A new complaint.
21:35And so the the approach can be similar.
21:39You know, I think, here what,
21:40what and I do.
21:41See cases or residents that present
21:44cases like this lot is that there is a.
21:47An assumption about,
21:48you know the links between the
21:50data points that are here,
21:52but but not enough consideration of
21:55other alternatives and and and then
21:58thinking about how that might affect
22:00our differential and our initial,
22:02you know treatment plan right?
22:03So I think what I'm hearing from
22:05this case is that this person
22:07has kind of subacute to chronic
22:09fatigue and shortness of breath
22:11that we're attributing to anemia,
22:13which we are assuming is due to iron
22:16deficiency and from chronic GI bleeding.
22:18And that further that that GI
22:20bleeding is due to hemorrhoids,
22:22and that therefore it's relatively benign,
22:24and so we should do a,
22:27you know,
22:28I now ask AP and look for hemorrhoids.
22:30And then you know,
22:31checking the hemoglobin again in
22:32a week and potentially doing a
22:34GI konsult or colonoscopy, right?
22:36So that may ultimately be true.
22:39I think there are some you know
22:41missing points here.
22:43You know,
22:43there's an assumption that this
22:45anemia is kind of, you know,
22:47subacute to chronic and.
22:49We don't have a presentation of of
22:51the of the baseline hemoglobin, right?
22:54We don't have a characterization of
22:56the anemia about whether it's due to
22:58iron deficiency or another cause, right?
23:01And then I think there's an issue.
23:02This is a woman who,
23:04according to the history is is still
23:07menstruating, not post menopausal,
23:08but there's some abnormal uterine
23:10bleeding here, and so is it.
23:12If it is from iron deficiency.
23:13Is it AGI? Kozora ginj cause.
23:17So I think there's there's.
23:19A lack of articulation of the
23:21differential at multiple levels right,
23:23not just is the complaint due to the anemia.
23:26What is anemia due to?
23:27And then if it is from chronic bleeding,
23:30where is the source of the bleeding
23:32and how it that be worked up.
23:34Last week point on May
23:352 is that you know the.
23:39You know another consideration
23:40on the outpatient side, right?
23:41Is that you know I don't have an
23:43osca P in my office right now.
23:45I think that I don't know how many
23:47primary doctors do or practice alongside
23:49a gastroenterologist who could do a,
23:51you know, in a sigmoid osca P
23:54or an Oscar that day, right?
23:56But I think learners often
23:57on the outpatient side,
23:59fail to consider like what is
24:01available now and what can be done.
24:03You know,
24:03expeditious way,
24:04you know they're used to take care of
24:06patients in the hospital who before
24:07there was a shortage of lavender.
24:09Top tubes, right?
24:10We're getting a CBC every morning
24:11whether or not they needed it right,
24:13but this person may not come back
24:15for three months or ever right,
24:17and maybe you check their labs and
24:18they don't have a working phone number
24:20and you can't get in touch with them
24:21when you they need blood transfusion,
24:22right?
24:23And so the part of the clinical
24:24reasoning on the outpatient side
24:26is not just what is the diagnosis,
24:28but you know how worried are
24:30we about the more and you know
24:33immediately concerning diagnosis
24:34and then how does that affect our?
24:37Our diagnostic pathway.
24:40Great thanks Ben, and that's a great point.
24:42I think I mentioned triage in the
24:45setting of the step down unit,
24:47but in the outpatient setting
24:49more than anyplace else.
24:50Maybe because you know right?
24:53Within prioritizing differential,
24:54it's just is this patient sick or not sick,
24:57you know so. Alright,
25:00so let's move on to case two.
25:04So this actually a real case of mine.
25:08We a learner who is prepping for
25:11their Saba and this is in the
25:13setting of the inpatient wards.
25:15The presentation they were practicing
25:17oral presentation on rounds and we
25:19had a a man who had been hospitalized
25:22previously for COVID was returning
25:24with shortness of breath and hypoxia
25:26diagnosed with a right lower lobe pneumonia.
25:29And happen mostly getting better
25:31over the week or so on antibiotics,
25:34but just wasn't getting better enough.
25:37So we got a CT scan on her after having
25:41a D dimer which was elevated to 16.
25:44So this is the previous day before the
25:47learner presented and overnight the
25:49patient was found to have a pulmonary
25:51embolism with an echo pending overnight
25:53in the setting of stable hemodynamics,
25:57normal tropes, and BMP.
26:00So we, oh,
26:01I'll be presenting to a Chris this time and
26:06so this was the results for our last poll.
26:10I'll bring up our next poll soon, but Chris
26:13presenting to you so this is our patient.
26:18Mr X overnight there weren't any events
26:22subjectively when I saw him this morning,
26:24he said that his cough and breathing
26:27had improved.
26:28Vitals were stable.
26:30Overnight look comfortable to me.
26:33Normal, cephalic,
26:34atraumatic pupils.
26:35Equal round reactive to
26:37light breathing comfortably.
26:39There was that that crazy that the
26:41crackles and diminished sounds at the
26:43right base normal active bowel sounds
26:45AO times 4 cranial nerves intact.
26:48Normal BMP AST was a little bit elevated
26:52to 45. There was a Leukocytosis.
26:54Went up a little bit to 18.9 and there
26:57was a CTA showing a pulmonary embolism so.
27:01This is a 78 year old man with a
27:05recent diagnosis of kovid and ammonia,
27:08admitting with the bacterial pneumonia,
27:09who's improving on antibiotics
27:11for the pneumonia? Will she?
27:14He's completing his seven day course
27:17of antibiotics today will be off.
27:19The oxygen will get for the PE will
27:22continue the heparin drip and we'll
27:24get a TTE today and the patient will
27:28stay on the floors for right now so.
27:31I'm going to leave that up there and
27:34I'm going to give our poll again.
27:36Alright, so we're going to actually.
27:42Maybe restart the pole to the relaunch pole.
27:47Great, it's alright.
27:48So we gotta pull up here.
27:50I want y'all to tell us where you think
27:53this learner is struggling the most.
27:56I will to their credit for those who
27:58are saying problem representation
28:00the people the student did know
28:02which gender the patient was OK so
28:04they at least get points for that.
28:07Alright, so we or numbers are coming
28:11up great and as Chris is thinking
28:13about how he did valuate this patient.
28:16Or this student? Once again,
28:19this is a patient who had a pneumonia,
28:22was diagnosed with a PE overnight,
28:25and had a Pte pending for them.
28:36Right?
28:39Great. Alright, I'm end pulling sharing
28:43the results for everybody. Lots
28:46of stuff going on with this
28:47learner and I agree. So a Chris.
28:50What are your thoughts about this learner?
28:54I'll go back to the case actually.
28:59Thanks Salon, you know this.
29:03Right for me.
29:04There's obviously multiple.
29:06I think issues going on in
29:09in in different domains.
29:11Obviously the most striking.
29:15Aspect of this is that the new
29:19finding of a PE is being kind of
29:23underplayed such that it's not even
29:26included in the overall assessment.
29:28And this is actually quite common,
29:31I think in in in terms of.
29:35Supervising learners in the inpatient space,
29:38I think that I often find that I don't know.
29:43I I often think about it as sort of like.
29:45For rest and treat issues where learners
29:50often have trouble toggling between the
29:54individual issues and the bigger picture,
29:58and then sometimes even
29:59within the individual issues,
30:00it can be difficult to keep them all.
30:04Kind of, you know on the desktop,
30:06so to speak,
30:08simultaneously and and prioritize between
30:11them so you know the to me that the the.
30:16The issue here instead of just focusing
30:18on pneumonia really is is is really,
30:23you know what I one of the the strategies
30:27that I would employ with this learner
30:30is to try and direct them to really
30:34consider the patients respiratory
30:36status and breathing complaints as a
30:39whole sort of on a more macroscopic
30:42level and then sort of dialing in on.
30:46What are the various components
30:48that are contributing to that?
30:51A superimposed bacterial pneumonia?
30:53A new diagnosis of a pulmonary embolism?
30:56What's the, you know?
30:58What's the backdrop of of COVID here?
31:01Because it's obviously not unrelated.
31:03And who knows,
31:05maybe we need to be thinking
31:07about additional other things so.
31:10To me that would be the foothold
31:13or or sort of the.
31:16Place that I would start and and and
31:19engage this learner in a discussion and
31:21maybe then kind of get at where they
31:24were coming from and and and what why
31:27it was they maybe felt like they were
31:29so sort of focused on the the pneumonia.
31:33And to the exclusion of other things.
31:36Yeah, and you know I agree with the
31:39group and I put up the pole with
31:41the results were definitely issues
31:43with this learner across the board.
31:46My biggest take as far as why I put
31:48problem representation as part of this
31:50is that the learner just didn't know
31:52what was going on and what was most
31:54important to the patient and maybe I see
31:59doctor Lancaster here asking about that.
32:02Whether the you know the
32:04practice of cut and paste right?
32:05So this learner was picking up the patient.
32:08From the previous day,
32:09and maybe had just like folks like.
32:11Alright, this pneumonia,
32:12pneumonia, pneumonia like appease
32:13their I'm reporting a CTA.
32:14But actually like what was new and
32:17dynamic was that this patient had a
32:19PE and it did make me wonder also
32:21about the learners ability to collect
32:24information also from the chart,
32:25but as you would imagine that it
32:27would affect things downstream.
32:29So in this patient you know
32:30as you're as you're you know,
32:32on the boards in clinic trying to figure
32:34out what teaching point for your learners.
32:37I think I probably would have
32:39focused on those. 2 steps at least.
32:41Just because we knew that the patient
32:43had a pulmonary embolism right now and
32:46it was being reasonably well managed,
32:49though there are certainly other
32:51things that we could do.
32:52And there weren't like other new
32:54like diagnosis that we were working
32:55up at that point,
32:56so that's why I probably would
32:58focus on those two topics.
32:59But honestly,
33:00when you're teaching on the fly,
33:02sometimes you just have to
33:04pick what's most compelling.
33:05So next,
33:06we're going to move on to case three
33:09with Emily, so this is we have an in.
33:12We're on the inpatient ID console
33:15service we are working with a
33:17fellow and we're staffing a new
33:19console at the end of the day,
33:21so our situation is so we have a 62 year old,
33:25previously healthy woman who presents with
33:27syncope in the setting of fever on arrival.
33:30Since the admission 4 days ago,
33:32neurological symptoms resolved.
33:33In fact,
33:34they resolved in the ambulance.
33:36On the way to the hospital,
33:37but the patient is still having
33:40fevers at night while on antibiotics
33:43for a possible pneumonia.
33:45Alright, so here is our know.
33:48Emily you ready for this?
33:49I I apologize if this isn't quite
33:51the caliber of your fellows.
33:52I had to simulate what it's like
33:54to be a fellow.
33:55Really get into that mindset is it's
33:57not what my champ and that meant I
33:58had to do an ID history which is
34:00asking about all these questions.
34:02I might not always do so anyway,
34:06so the reason for console doctor
34:07AB dollar is you know this is 62
34:10year old previously healthy woman
34:12presented with syncope in the
34:13setting of fever Leukocytosis.
34:15Elevated procul,
34:16CRP and lactate being treated with them.
34:20Pneumonia with ceftriaxone and
34:21doxycycline since admission or sing
34:23to me in all that has gotten better,
34:25but she still has a fever.
34:28The fever ranges from 100 to 102 occurring
34:31at various times during the day.
34:33Worker has been unraveling with you.
34:35A bland cultures,
34:37negative respiratory viral panel,
34:39negative X ray didn't really show
34:42anything to be honest and that CT
34:44abdomen pelvis that they got a couple
34:46days ago was also unremarkable.
34:48On my history, she endorsed a 10 to 15
34:50pound weight loss over the past few months.
34:53I wasn't really sure if it was intentional,
34:54unintentional,
34:55but didn't really have any other symptoms.
35:00** *** denied any travel or
35:02tick or animal exposures.
35:04Emily, that's something that we have
35:05to ask now that we're in Connecticut.
35:06Everybody has like potential tick exposures.
35:09She's not sexually active,
35:10nor does she have a history of STI's
35:14not on any meds or other antibiotics,
35:16for example,
35:17is pretty unremarkable looking
35:19clinically quite well without any
35:22adventitious cardiac or pulmonary sounds.
35:24In addition to having a benign
35:26abdominal and neurological exam,
35:28she didn't really have any rashes either, so.
35:30You know, if I had to sum it up,
35:32we have a case of fever,
35:33fever of unknown origin,
35:35plus minus in an elderly woman with
35:38elevated inflammatory markers currently
35:40on antibiotics with clinical improvement
35:42but persistent fever most likely.
35:44Etiology is resolving viral process
35:46as it's not really responding.
35:48Antibiotics maybe a cavitating
35:50bacterial pneumonia Abscess,
35:52but it seems less likely she
35:54doesn't really seem sick.
35:55Maybe a drug reaction.
35:56That said,
35:57the primary teams pretty worried
35:58and they did call us so.
36:00You know we could broaden the antibiotics.
36:03And also, you know,
36:04maybe we could just do like a broader
36:06work up to rule other things out.
36:08There was a weight loss so
36:09we can get a quantum goal.
36:11We can check some of those urine antigens.
36:13We can send some fungal studies to,
36:16maybe check for Lyme as well.
36:18I know she didn't say that she had any
36:20exposures and other tick borne illnesses.
36:22I probably wouldn't get a CT chest
36:24yet or or call palm for abroad,
36:26but we could start considering it.
36:28I will say this though,
36:29the patient really wants to be discharged
36:31soon as she's been feeling well for a while.
36:33So I'm going to relaunch our poll.
36:37For everybody to think about and
36:40start thinking about where you
36:43would diagnose where this learner
36:46might be struggling right now.
36:49And, uh,
36:50yeah,
36:50I'll give a few minutes for not
36:53a few minutes a few seconds
36:55for everybody to chime in.
37:01Also, to hydrate as you know,
37:03excited as I am to play
37:05these as these characters.
37:06Certainly it takes a toll
37:08on the hydration status.
37:10Alright, so we have 20 there.
37:11Can we get a few more folks
37:13to participate in the poll?
37:16Right? Alright ending
37:20poll. Sharing our results of
37:22what's going on with this learner.
37:25Alright, Emily, I thought
37:26this was a management case.
37:28Totally fair for other things
37:30to be going on to Emily.
37:32What is what are your
37:34thoughts on our fellow here?
37:37So thanks, Salon, and this is such
37:39a good case to bring out from a
37:42from an ID con cult perspective I
37:44I really marked that the learner
37:46was struggling in all of the areas
37:49and like you mentioned earlier,
37:50it has spilled over effect into
37:53this up into the subsequent sort
37:55of steps in in clinical reasoning,
37:58culminating in a lot of sort
38:01of management errors here,
38:03I think that you know you could
38:05trace this back to data collection
38:07and I saw that that was low.
38:10In terms of where people thought
38:11that the learner had struggled and
38:13and certainly there's a lot of,
38:15there's a lot of data collected,
38:16but maybe not all the data that
38:18needs to be collected,
38:19and maybe some data that that
38:21shouldn't have been collected.
38:23I tend to think especially as
38:25an ID consultant.
38:26Every sort of follow-up
38:27question I ask that gets,
38:29you know,
38:29really personal or even odd and and
38:31gets raised eyebrows from the patient,
38:34is another diagnostic test.
38:35Is a management step for me
38:38because it's time and.
38:39It's getting into somebody's
38:41personal history,
38:42and so I think there were some
38:43problems with that here and asking
38:45questions that maybe didn't need
38:47to be asked yet and maybe avoiding
38:49or not asking some questions that
38:50that should have been asked and
38:52then from there there's really,
38:54you know,
38:55there's the focus on the persistent fever,
38:57but they they sort of leave out what,
39:01if anything, is localising here?
39:03What about the syncope did we ever
39:05come up with a reason for it as an ID
39:08consultant I get to leave other causes.
39:11Beside,
39:11besides sepsis to the side,
39:14which is a great part of sub
39:16specializing for me but I I don't
39:19really get how that's fitting in.
39:21If it's fitting in nor anything
39:22about the fact that this is
39:24being called in pneumonia,
39:26but there was nothing on imaging nor
39:28any sort of respiratory symptoms or
39:31respiratory abnormalities that would
39:33make that where we hang our hat from there.
39:36Like let's say that we had
39:37broken things down and had a
39:39good problem representation,
39:40I think.
39:41But the the management here is
39:42just sort of scattered all over the
39:44place and I think something like
39:46a management script which you've
39:48alluded to several times in here.
39:50And of course I have you and Andrew
39:52to thank for that could be really
39:55helpful for organizing the steps to
39:58take in terms of working this up
40:00further thinking about So what other history?
40:03What other questions do we want to ask
40:05if we're considering that a diagnostic test?
40:07But what lab tests would we prioritize
40:09out of all the different ones?
40:11You could send what imaging studies
40:13would we think about what treatments
40:16or procedures would be necessary,
40:19really?
40:19Categorizing it to think about each
40:21thing in detail and what we're going
40:23to do and what we aren't going to do
40:25and in terms of making that decision.
40:27This is where you could talk
40:30about thresholds quite a
40:31bit because the the learner hasn't
40:34really insinuated how these different
40:36tests are going to help them.
40:38So for instance, the threshold for getting.
40:41Getting a Quantiferon if even
40:43outside of like Bayesian reasoning.
40:45If we're just thinking,
40:46does that make me automatically
40:48assume this is this is disseminated
40:51tuberculosis or pulmonary tuberculosis?
40:53What's what's going to change based
40:55on on the results of that test and
40:58in terms of helping the learner
41:00think about should we get it or not?
41:02Is it going to change our management?
41:04Is it going to influence our differential
41:07diagnosis so this would be this
41:09would be sort of a a terrifying.
41:12Presentation to get 'cause it
41:13would mean a lot more work to do to
41:16sort of ask the right questions.
41:18Figure out what really is the
41:20problem we're trying to address.
41:22Classify the different options into
41:25a nice management script and then
41:27talk about thresholds for testing
41:30and treatment in this.
41:31In this sort of in this case.
41:34So thank you for giving me a challenging one,
41:37so we'll pretend this is an
41:40early first year fellow.
41:41But one question I had for you
41:43Emily when it comes to management.
41:45I was talking to no file bar.
41:47One of our hematologists and she said that
41:51oftentimes when she 'cause she really.
41:53Thinks about high value care two
41:55and testing that she feels like
41:57her fellows feel like forced to
41:58like give all of these like tests.
42:00Do you find that coming up a lot
42:02and like like how much do you feel
42:05like it's pressure to provide some
42:07sort of recommendations versus them
42:09actually thinking that you have
42:10to do everything?
42:11Yeah, that's a great question and I
42:14think that does come up for consultants
42:16because you're being asked to help in a
42:19situation and so helping means if not,
42:21if not treating the problem,
42:22at least trying to.
42:24Figure out what what it is.
42:26I think in the same way though,
42:29a lot of I know a lot of medicine
42:31and certainly subspecialty medicine
42:32is not sending every every
42:35test that you possibly can.
42:37That that's where the history comes in.
42:40And and then you put on here,
42:41not patient,
42:42centered and I meant to talk about that too,
42:44because this is where you know you
42:46you have a patient who is feeling OK,
42:49who's ready to go home,
42:51who may be having drug fever to
42:52antibiotics that they don't.
42:54Need and then you're going to force this.
42:56All this work upon them without
42:58sort of talking to them about what
43:00might what might be warranted,
43:02and what steps might fit into
43:03their plan and say, follow up.
43:05And that sort of thing.
43:06Yeah, and hopefully that helps to write,
43:08like invoking like being patient
43:10centered as well to cone things down.
43:12So thanks all, Chris,
43:15Ben and Emily for talk about those cases,
43:18hopefully for you on the audience.
43:20Just having these conversations is helpful,
43:22because honestly,
43:22we don't get to see each other.
43:25Each clinical reasoning
43:26very often and assess it,
43:28so hopefully that's been helpful.
43:30I want to give a quick plug about
43:33Untrustable professional activities,
43:34not just because Dean is running this course,
43:35but also it's one of the main things
43:37that we think about when it comes to
43:40assessment across various parameters.
43:42I tried to give an image of,
43:43you know, something that requires
43:45trust where you have to be caught.
43:47My daughter has actually been doing
43:48this a lot lately which is very cute,
43:50but leaning back and terrifying
43:52as well as far as you know.
43:55Potentially a trusting others to catch her.
43:58So which is an untrustable
44:00professional activity.
44:01So EPA's are a unit of professional
44:03practice that can be entrusted to a
44:05training as soon as they have demonstrated
44:08competence to execute that activity.
44:10So we talk about competencies all the time,
44:13and EPA's are just a nice way to give
44:16a specific skill for us to examine.
44:19Because these are the things what
44:21learners are actually doing,
44:22and they can fit across multiple
44:24different competencies.
44:25There are various scales.
44:26For example,
44:27if you have a student who's on
44:28clerkships that you might be,
44:29or clinical rotations that you
44:31might be asked to evaluate.
44:33The Co activity scale,
44:34which is what you're doing when you're
44:36filling your having your student
44:38fill out that email or pull for you
44:40is breaking it down from I did it,
44:43which really required complete
44:44hands on guidance to.
44:46I talked them through it too.
44:48I directed them from time to time.
44:51They need a little bit help too.
44:54I was available just.
44:56Same case versus completely
44:58not needing to be supervised
45:00and functioning independently,
45:03which is I did not need to be there.
45:05OK, so we're gonna have one more case.
45:07I want you to think about these broad
45:10this categories of scale because
45:12this actually comes up when you
45:14see students on your IM clerkship.
45:16There's a supervisory scale of Epas,
45:18but that's not really what you're
45:20doing when you're on these rotations.
45:22I will say if you really go into
45:25the deep dive.
45:26I know Michael Greens on this call.
45:27He was part of our EPA pilot.
45:29There are specific behaviors related to
45:32the EPA's and if you deconstruct it,
45:34it's similar to that assessment
45:36of reasoning tool gathering data,
45:38synthesizing it so a problem representation,
45:41prioritizing a differential,
45:42making sure you're doing high value
45:44care so those same principles still apply.
45:46So I want to reinforce that
45:48these aren't different things,
45:49ones just more holistic than the other.
45:52Alright,
45:53so our 4th diagnosis we get to watch a
45:56video of me when I was a you know five
45:59years ago time has taken its
46:01toll so I appreciate your
46:03watching as we see a learnable.
46:05Honestly could have been in the
46:06inpatient or outpatient setting.
46:07A clerkship clinical student
46:09staffing a patient of an 18 year
46:12old woman presenting with acute
46:14severe left lower quadrant pain in
46:16the setting of nausea and vomiting,
46:19but no dis urea was found to be takach
46:22Arctic and mildly febrile to 99.
46:24On their exam.
46:26So we're thinking about these
46:29steps from I did it to.
46:30I did not need to be there.
46:32I'll bring the pole up as we go.
46:37Let's see cancel.
46:39I'll actually change the pole right here.
46:42Alright,
46:43I'm launching this poll for
46:44y'all to watch this video and
46:46get an idea of where you think
46:47our learner is alright.
46:51For your viewing pleasure.
46:56So I'm sorry I got
46:58a chance to look at
46:59your note for the patient
47:01that you just saw. Would
47:02it be OK if you talk about?
47:05So could you give me a general overview
47:08of the patient
47:09share so this is an 18 year old
47:12woman coming in with a few hours of
47:14left lower corner of Domino pain,
47:16who's had a previous history of UTI's OK,
47:20and So what is your differential
47:23diagnosis for her?
47:24So my top diagnosis is UTI,
47:27specially governor history and the lower
47:30abdominal pain and also just because
47:32she had mentioned that moved to the flank.
47:35I also did a pilona frites and then maybe
47:38a kidney stone that for all of that OK.
47:42What are used for and against each diagnosis?
47:46I think for the UTI is
47:49acute onset pretty painful.
47:51Kind of around the area you would
47:53have pain and she found history of it.
47:56And how do you reconcile the fact
47:57that she didn't have any dysuria?
48:01Well, she was in a lot of pain like
48:02she had a lot of abdominal pain when I
48:05used amateur and then I'm thinking if
48:07she had that pain especially when she
48:09was staring down or using the bathroom.
48:12Maybe she didn't notice that
48:14there was to Syria.
48:16Did you consider any other systems
48:19or causes, for example gynecological
48:21diagnosis like ovarian,
48:24torsion or gastrointestinal
48:26causes like diverticulitis?
48:31I don't really know anything
48:32about their intelligent.
48:34Haven't done my obj rotation so
48:35I didn't consider that at all.
48:37'cause I don't know really what it is.
48:41Diverticulitis, yeah, I guess it
48:43is also on the left lower quadrant.
48:46I didn't consider it,
48:47but it is the same area.
48:50Looking back on it,
48:52that broader differential diagnosis.
48:53Do you think there's anything
48:55you would have done differently
48:56on your history and physical
48:58to better tease those out?
49:02No, really, I did that domnul exam.
49:06So what about for a testing?
49:11Well, I'm gonna get the CT after then
49:13and I think that'll be really useful.
49:15You know even before,
49:16even though I think it's a UTI,
49:19the CTI will be really useful for
49:22figuring out if it's a kidney stone.
49:25Is there any concerns you have about
49:27ordering a CT scan in this patient?
49:33This is radiation. Yeah yeah,
49:37OK. Sounds good. Was
49:39there anything else
49:40you could think about this case?
49:43Uhm?
49:46I mean, I guess she had mentioned
49:48some other things, I just didn't
49:50mention them because I didn't think.
49:52It was relevant, especially since
49:53it's pretty sure it was a UGI.
49:55OK, like what she had mentioned actually that
49:58she had vomited twice in the past hours,
50:01but I thought that like given it was a UTI,
50:05that might be something else.
50:06Maybe it's just something
50:07she eat and it wasn't.
50:09It wasn't bilius OK was.
50:12Would that potentially have changed
50:14your differential at all?
50:17No, no. Well, sometimes conditions
50:21that you mentioned in your
50:22differential like natural phthisis
50:24or maybe a variant portion that we
50:27talked about might be more likely to
50:29present with those types of symptoms.
50:30So something could consider OK, alright?
50:35Alright, so get your answers into the pole.
50:39Appreciate you watching that video.
50:40Part of why I wanted to do that is
50:43because honestly, as you can see,
50:45teasing out a learners clinical
50:46reasoning isn't necessarily like
50:48you just get a presentation.
50:49You're diagnosing the learner there,
50:51no pun intended, right?
50:52Like you're having a conversation with them,
50:54like pushing and pulling, exploring,
50:57you know what exactly they
50:58meant in the in the situation,
51:01so I think that's something
51:03to remember as well.
51:04Just as we're suspending our
51:06disbelief for some of these.
51:07In other cases,
51:08so we have some folks wrapping up this poll.
51:12We're at 17, nineteen, 20 now,
51:14but where we think our learner is?
51:16Oh, this is interesting.
51:20Great, I'm gonna share the answer.
51:22I also appreciate Joe writing
51:23on that pole right now.
51:25Great, so we're going to share the results.
51:29Of this, and I think that so the range
51:34for this learner is between I did it
51:37versus I talked them through it to I
51:40directed them from time to time and I
51:42think all of these are honestly fair.
51:44I probably would have the
51:46learner somewhere in here,
51:47but I think I might have
51:49been generous with that too.
51:50I probably say would say a 2,
51:52but for anybody who said I did they
51:55they thought it was more A1A level one.
51:58If I did it.
51:59Anybody wanna share with their
52:00thought processes on that?
52:08Sure, I'll go ahead.
52:10So this is Mitchell
52:11Choksey, why not
52:13I. I don't mean to be hard
52:16on the learner, but she's new.
52:20And clearly hasn't had the
52:22experience to tease out what
52:24most of us would consider as the
52:26most critical. You know,
52:29pregnancy test ectopics ovarian torsion,
52:32which other ones which are more of
52:34an urgent situation than a UTI.
52:36You know if if I had you know
52:38if I had to triage a patient,
52:40that's probably the first thing
52:42I'd look at and not, you know,
52:44definitely not a UTI, and definitely
52:46not a **** scan
52:47before you decide
52:48to do the basics,
52:49which is a pregnancy test so.
52:51And so I'm very uncomfortable
52:53moving them to a two,
52:54and I think this still has a one.
52:57First off, I want to say you you really
53:00cage that nicely for the learner,
53:02but I also think that's I.
53:04I appreciate that and I think
53:06that's honestly brave to really
53:08be honest with your learner,
53:09I'm doing that recently talked about
53:12learner who's struggling their clinical
53:14reasoning because we identified how
53:16much they were struggling early on.
53:18We were able to get that learner.
53:19A lot of support,
53:20and so I think you know this is
53:22totally fair to say we had to be hands
53:25on to make sure our learner caught.
53:27The major parts of this case,
53:31and then their clinical reasoning,
53:32so hopefully that was an example of how
53:35you can work through this case through Epas,
53:38which you'll be seeing often.
53:39I'll hold off talking about assessment
53:41of reasoning tool in these steps,
53:43because as you can see,
53:45there were issues across the board
53:48starting from data collection.
53:49But as we wrap up and we only
53:51have a few minutes left,
53:53I did want to share some Grodd strategies
53:56for teaching clinical reasoning, which.
53:59I break down into the categories
54:02of clarification,
54:02asking open-ended questions, observing them,
54:06providing scaffolds or schema.
54:07Once again,
54:08all of these are in the link,
54:10though I I it seems like there's
54:12a firewall for some of y'all who
54:14are at the hospital right now.
54:16Feel free to email me afterwards
54:17and I can send that to you modeling,
54:20so this is one of the more
54:22efficient ways honestly,
54:23and I think our learners appreciate that.
54:25Thinking out loud,
54:26showing them what you would
54:28do in a given situation.
54:30And giving them self directed
54:31learning like I mentioned earlier,
54:33knowledge is a big part of clinical
54:35reasoning and some of our learners
54:37just struggle so much with all the
54:39stuff that they can learn and know
54:41and resources and so pointing them
54:43in the right direction of like hey,
54:45I recommend you know this review article
54:47to help flesh out your differential well
54:49I remember listening to this podcast.
54:51I recommend the clinical problem solvers
54:53all the time and I know we talked about
54:56some teaching strategies along the way,
54:58so I think we can hold off.
55:00These specific ones I will mention in
55:04general when it comes to management,
55:06Emily mentioned a management script that
55:08Andrew and I talk about not infrequently,
55:11which is just saying hey,
55:12these are categories of options labs,
55:16imaging procedures,
55:17specialist medication monitoring
55:18tests or treatment which can
55:21just help prompt a learner,
55:22particularly in that student
55:24range who honestly can come up,
55:26probably with a differential,
55:27but might struggle just
55:28coming up with any management.
55:30Options because they haven't
55:31been in that setting,
55:32so I wanted to give a couple minutes for
55:37Michael or anybody else to ask questions,
55:41but hopefully from this
55:43talk we've reviewed some,
55:45we've reviewed diagnostic error and
55:48some core assessment terminology from
55:51data collection problem representation,
55:53prioritizing differential management
55:54in the setting of the assessment
55:57of reasoning tool.
55:58We also talked about the EPA specifically
56:02for prioritizing differentials.
56:03So I'm gonna hang on for anybody
56:05who has a questions or thoughts,
56:08but I appreciate your coming and
56:10we're gonna ask some question.
56:11Ask some questions so Michael,
56:13I know you had a question.
56:19I was muted, wasn't I?
56:21Thanks to you and your team,
56:23and this question is motivated in part.
56:27By us preparing our documentation
56:29for the LC Me visit,
56:32but all of your vignettes had
56:34to do with offering formative
56:37feedback to to learners.
56:39Do you have recommendations
56:41for summative assessments of
56:43clinical reasoning? Yeah.
56:47It can be hard honestly.
56:48Probably the best one is what
56:51we do with OS keys and you know,
56:53I do think at the end of a rotation
56:56you have enough of these formative
56:58assessments to give feedback to alert.
57:00So that's like the in vitro versus
57:02in vivo right end of clerkship grade,
57:05and those like work based
57:07assessments are valuable.
57:08But those are our big ones.
57:10There isn't like a formal summative
57:12evaluation that we can feel really confident
57:15that we know where our learner is.
57:17You just need to make sure you have
57:19enough like examples of them doing
57:21whatever test it is in the formative
57:23fashion to use those same principles
57:26for summative evaluation too, thanks.
57:32OK great well thanks everybody
57:34for hopping on taking some time
57:36out of your noon hour and
57:38feel free to email me.
57:40Reach out with questions,
57:41appreciate all of my Co presenters to Ben,
57:44Chris, Emily and Andrew.
57:45Thank you so very much and
57:48have a great weekend y'all.
57:50Come on, do you want to put up
57:51the QR code for the survey? For
57:53this yeah yeah yeah
57:55people can maybe I don't know if you have.
57:57It also has a link. Yes, there it is.
58:00If maybe you can put that in the chat.
58:02Great thanks everybody.
58:04Let us know if you did not get the.
58:08Document. We could email that to you and we
58:12really appreciate your your feedback and
58:16I appreciate you and your team that came.
58:18I know an hour is always way not long enough.
58:22Maybe we'll try to do round two with
58:24some more time for some of these.
58:26I know people really get interested
58:28in how to help all beyond those those.
58:31Some of the things that you were
58:33starting to outline.
58:34Some resources for that. That we can use.
58:37Thank you very much.
58:39Alright thanks y'all.