Teaching and Assessing Critical Reasoning in the Era of
Competency-based Medical Education, Milestones and
Entrustment
Preventing Diagnostic Error
“We’re pretty sure it’s the West Nile virus.”
Clinical Reasoning: A Primer
Patient/situation
characteristicsPrior knowledge
Problem Representation
Information GatheringContext
Evaluation Action
Gruppen and Frohna, International Handbook on Research, 2002
Clinical Reasoning
Internal process Trainees and faculty need ways to
externalize and teach this process Programs need assessment methods that
document growth and competency in this skill
Critical Thinking Good Thinking
– Sensitivity• Interest in gaining
more information• Seeking
alternatives– Inclination
• Willing to invest energy in thinking the matter through
– Ability• Possess the
cognitive ability
“Bad Thinking” – “cognitive misers”– Chose to take
mental shortcuts, engage in heuristic thinking,
– without interest in “good thinking”
Krupat 2011
Adverse Events and Clinical Reasoning
Graber¹ adverse event study:– Most errors combination of individual and
systems factors– Average 5.9 system +/- cognitive error per case
“Cognitive factors” – 320 cognitive factors in 74 cases– 45 due to faulty data gathering– 264 due to faulty synthesis (problem
representation – clinical reasoning)
¹ Arch Intern Med. 2005; 165: 1493.
The Process of Clinical Reasoning
How can clinical reasoning be taught and assessed in a
competency-based system to reduce diagnostic error?
CBME - a new paradigm
You must truly know the trainee has demonstrated competence and is ready to progress to the next stage of their training or career:• Requires clear definition of expected outcomes
(“good thinking” with decrease in diagnostic errors)
• Requires assessment and evaluation systems capable of demonstrating that these things are done consistently and within the contextual needs of the clinical environment
Requirements
– The content of “good thinking”• Define the K/S/A of “good thinking” and frame as
an entrustment– An assessment and evaluation system– Faculty Development – creating a shared
“mental model” or understanding of “good thinking” and how it is assessed and evaluated
The Content - Twelve Tips “to prevent diagnostic error”
Understand heuristics Use “diagnostic timeouts” Think “worst-case scenario medicine” Systematic approach to common problems Ask why Teach/emphasize physical exam Teach Bayesian theory Acknowledge your emotions Identify what doesn’t fit Embrace zebras “Slow down” Admit mistakes
Trowbridge Medical Teacher 2008
The “Twelve Tips” and the Internal Medicine Curricular Milestones
142 discrete milestones published in 2009 Describe developmentally the discrete K/S/A
needed for competency in the six ACGME General Competencies
Cross walking the 12 tips against the milestones identifies at least 28 milestones that capture the knowledge, skills or attitudes that could be used to teach and assess critical reasoning.
Patient Care
ACGMECompetency
Developmental Milestones InformingACGME Competencies
ApproximateTime FrameTrainee to Achieve Stage
Assessment Methods/Tools
Clinical skills and reasoning
Manages patients using clinical skills of interviewing and physical examination
Historical Data Gathering1. Acquire accurate and relevant history
from the patient in an efficiently customized, prioritized, and hypothesis driven fashion
2. Seek and obtain appropriate, verified, and prioritized data from secondary sources (e.g. family, records, pharmacy)
3. Obtain relevant historical subtleties that inform and prioritize both differential diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient
6 months
9 months
18 months
Standardized patient
Direct Observation
Simulation
Sub-competency
“Entrustment in Medical Education”
Focused assessments around what faculty and training programs “entrust” trainees to do?
Think critically to minimize error
Reflects the most important outcome of training: a trainee’s readiness to bear professional responsibility”
http://www.im.org/AcademicAffairs/milestones/Pages/default.aspx
How do I develop an assessment?
Step 1 – Describe the activity. What tasks constitute the entrustment.
Step 2 – Identify the Curricular Milestones (142) that will help you assess a resident performing this activity.
Step 3 – Identify specific assessment methods / tools to which you can apply the chosen Curricular Milestones.
Clinical Reasoning
Step 1 – Describe the activity. What tasks are required for you to entrust this activity to a resident?
The “Good Thinker” as described by the twelve tips cross walked to the Internal Medicine
Curricular Milestones.
Twelve Tips “to prevent diagnostic error” – The “Good Thinker” Entrustment
Understand heuristics Use “diagnostic timeouts” Think “worst-case scenario medicine” Systematic approach to common problems Ask why Teach/emphasize physical exam Teach Bayesian theory Acknowledge your emotions Identify what doesn’t fit Embrace zebras “Slow down” Admit mistakes
Trowbridge Medical Teacher 2008
Clinical ReasoningStep 2 – Identify the Curricular Milestones (142) that will help you assess a resident performing this activity
Key Considerations:• What Curricular Milestones are best assessed in this
setting? … in this context?• You don’t have to choose all milestones, only those
that will help you to “see” competence in the trainee.• Crosswalk the twelve tips and the 142 curricular
milestones.
Understand heurisitcs 1. MK -1- Demonstrate sufficient knowledge to diagnose and treat undifferentiated and
emergent conditions Use “diagnostic timeouts”
1. PC 3 - Modify differential diagnosis and care plan based upon clinical course and data as appropriate
2. PBLI – 6 - Actively seek feedback from all members of the health care team 3. PBLI – 6 - Calibrate self-assessment with feedback and other external data 4. PBLI – 6 - Reflect on feedback in developing plans for improvement
Think “worst-case scenario medicine” 1. MK 1 - Understand the relevant pathophysiology and basic science for uncommon or
complex medical conditions 2. MK 1 - Demonstrate sufficient knowledge to evaluate complex or rare medical conditions
and multiple coexistent conditions 3. PC 6 - Manage complex or rare medical conditions
Systematic approach to common problems 1. PC 3 - Synthesize all available data, including interview, physical examination, and
preliminary laboratory data, to define each patient’s central clinical problem 2. MK 1 – Demonstrate sufficient knowledge to evaluate common ambulatory conditions 3. MK 1 - Demonstrate sufficient knowledge to diagnose and treat common conditions that
require hospitalization Ask why
1. PBLI 2 - Classify and precisely articulate clinical questions 2. PBLI 2 - Develop a system to track, pursue, and reflect on clinical questions
Teach/emphasize physical exam 1. PC 1 - Obtain relevant historical subtleties that inform and prioritize both differential
diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient
2. PC 2 - Routinely identify subtle or unusual physical findings that may influence clinical decision making, using advanced maneuvers where applicable
Teach Bayesian theory 1. MK 2 - Understand prior probability and test performance characteristics 2. SBP 5 - Minimize unnecessary care including tests, procedures, therapies and ambulatory or
hospital encounters 3. SPB 4 - - Understand how cost-benefit analysis is applied to patient care (i.e. via principles of
screening tests and the development of clinical guidelines) Acknowledge your emotions
1. P 6 - Recognize and address personal, psychological, and physical limitations that may affect professional performance
2. P 9 - Recognize and manage conflict when patient values differ from their own 3. P 5 - Recognize and manage subtler conflicts of interest
Identify what doesn’t fit 1. PBLI 5 - Determine if clinical evidence can be generalized to an individual patient 2. Patient care 3 - Recognize disease presentations that deviate from common patterns and
that require complex decision making Embrace zebras
1. MK 1 - Understand the relevant pathophysiology and basic science for uncommon or complex medical conditions
2. PK 6 - Manage complex or rare medical conditions “Slow down”
1. Maintain awareness of the situation in the moment, and respond to meet situational needs 2. Reflect (in action) when surprised, applies new insights to future clinical scenarios, and
reflects (on action) back on the process Admit mistakes
1. P 1 - Accept personal errors and honestly acknowledge them
Clinical ReasoningStep 3 – Identify specific assessment methods / tools to which you can apply the chosen Curricular Milestones.
Key Considerations:• What Curricular Milestones are best assessed in this
setting? … in this context?• You don’t have to choose all milestones, only those
that will help you to “see” competence in the trainee
Methods Portfolio – with required defense by learner
– Case log– Focused narrative writing– Admit mistakes
Chart stimulated recall– Structured questioning regarding the twelve tips
milestones Bedside rounds
– One minute preceptor– Time out
Please check ONLY ONE box per statement Y N NA
Clear chief complaint
Delineation of sick vs non-sick
Appropriate history
Appropriate physical
Appropriate analysis of lab data
Appropriate differential diagnosis
Appropriate thought process for differential diagnosis
Treatment appropriate for diagnosis
Appropriate thought process for treatment plan
Overall Note:Clarity____________________________________Organization__________________________________Internal consistency____________________________________Documentation____________________________________
The One Minute Preceptor – A Strategy For Busy Clinicians
Clinical teaching strategy 5 microskills
• Get a commitment• Probe for supporting evidence• Teach a general rule• Reinforce what was done right• Correct mistakes• “Create time for reflection”
Neher, Gordon, Meyer, Stevens. J Am Board Fam Pract 1992; 5:419-24.
“The System”
The Donobedian Framework – Schematic representation of a system
Every system has a structure and a process that processes that produce an outcome
S + P = OS(the when/where) + P (the teaching and
assessing) = O (“Good thinkers”)
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