Teaching and Assessing Critical Reasoning in the Era of
Competency-based Medical Education, Milestones and Entrustment
Preventing Diagnostic Error Slide 2 Were pretty sure its the West
Nile virus. Slide 3 Clinical Reasoning: A Primer Patient/situation
characteristics Prior knowledge Problem Representation Information
Gathering Context EvaluationAction Gruppen and Frohna,
International Handbook on Research, 2002 Slide 4 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 Slide 5 Slide 6 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 Slide 7 Adverse Events and Clinical Reasoning
Graber adverse event study: Most errors combination of individual
and systems factors Average 5.9 system +/- cognitive error per case
Cognitive factors 320 cognitive factors in 74 cases 45 due to
faulty data gathering 264 due to faulty synthesis (problem
representation clinical reasoning) Arch Intern Med. 2005; 165:
1493. Slide 8 Slide 9 The Process of Clinical Reasoning Slide 10
How can clinical reasoning be taught and assessed in a
competency-based system to reduce diagnostic error? Slide 11 CBME -
a new paradigm know 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 Slide 12 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 Slide 13 The Content - Twelve
Tips to prevent diagnostic error Understand heuristics Use
diagnostic timeouts Think worst-case scenario medicine Systematic
approach to common problems Ask why Teach/emphasize physical exam
Teach Bayesian theory Acknowledge your emotions Identify what
doesnt fit Embrace zebras Slow down Admit mistakes Trowbridge
Medical Teacher 2008 Slide 14 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. Slide 15 Patient Care ACGME
Competency Developmental Milestones Informing ACGME Competencies
Approximate Time Frame Trainee to Achieve Stage Assessment
Methods/Tools Clinical skills and reasoning Manages patients using
clinical skills of interviewing and physical examination Historical
Data Gathering 1.Acquire accurate and relevant history from the
patient in an efficiently customized, prioritized, and hypothesis
driven fashion 2. Seek and obtain appropriate, verified, and
prioritized data from secondary sources (e.g. family, records,
pharmacy) 3. Obtain relevant historical subtleties that inform and
prioritize both differential diagnoses and diagnostic plans,
including sensitive, complicated, and detailed information that may
not often be volunteered by the patient 6 months 9 months 18 months
Standardized patient Direct Observation Simulation Sub- competency
Slide 16 Entrustment in Medical Education Focused assessments
around what faculty and training programs entrust trainees to do?
Think critically to minimize error Reflects the most important
outcome of training: a trainees readiness to bear professional
responsibility Slide 17
http://www.im.org/AcademicAffairs/milestones/Pages/default.aspx
Slide 18 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. Slide 19 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.
Slide 20 Twelve Tips to prevent diagnostic error The Good Thinker
Entrustment Understand heuristics Use diagnostic timeouts Think
worst-case scenario medicine Systematic approach to common problems
Ask why Teach/emphasize physical exam Teach Bayesian theory
Acknowledge your emotions Identify what doesnt fit Embrace zebras
Slow down Admit mistakes Trowbridge Medical Teacher 2008 Slide 21
Clinical Reasoning Step 2 Identify the Curricular Milestones (142)
that will help you assess a resident performing this activity Key
Considerations: What Curricular Milestones are best assessed in
this setting? in this context? You dont have to choose all
milestones, only those that will help you to see competence in the
trainee. Crosswalk the twelve tips and the 142 curricular
milestones. Slide 22 Slide 23 Slide 24 Clinical Reasoning Step 3
Identify specific assessment methods / tools to which you can apply
the chosen Curricular Milestones. Key Considerations: What
Curricular Milestones are best assessed in this setting? in this
context? You dont have to choose all milestones, only those that
will help you to see competence in the trainee Slide 25 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 Slide 26 Please check ONLY ONE box per
statementYNNA 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____________________________________ Slide 27 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. Slide 28 The System The
Donobedian Framework Schematic representation of a system Every
system has a structure and a process that processes that produce an
outcome S + P = O S(the when/where) + P (the teaching and
assessing) = O (Good thinkers)
