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Hoofbeats: Hyponatremia Consult Case

Core IM

Clinical reasoning has traditionally been regarded as a cognitive process, however, it is also a contextually situated activity. Many contextual and environmental factors affect our cognitive load and reasoning approach. In addition, academic training often promote routine expertise where someone effectively uses sophisticated knowledge-memory structures to solve routine problems. In this episode of Core IM, the team will discuss a different kind of expertise as they explore adaptive expertise in Hoofbeats: Hyponatremia Consult Case.

First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

CME/MOC:

Up to 0.75 AMA PRA Category 1 Credits ™ and MOC Points
Expires January 28, 2025   active

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Free to Members

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Podcasts and Audio Content

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Core IM

Welcome to Core IM, a virtual medical community! Core IM strives to empower its colleagues of all levels and backgrounds with clinically applicable information as well as inspire curiosity and critical thinking. Core IM promotes its mission through podcasts and other multimodal dialogues. ACP has teamed up with Core IM to offer continuing medical education, available exclusively to ACP members by completing the CME/MOC quiz.

  1. Reasoning is not just a cognitive process, but also a contextually situated activity. We do not reason in a vacuum. Unfamiliar environment, ambiguous clinical questions, relative domain expertise, emotional interference, personal comfort level of the case are examples of many contextual factors that can add to one's cognitive load AND alter their reasoning approach.
  2. Situation awareness is something that precedes, prepares, and  “primes” our mode of thinking and is largely affected by a person’s goals and expectations. Having clearly defined clinical goals is crucial to effective reasoning.
  3. When someone needs to operate with insufficient domain knowledge, there is the natural tendency to slow down AND to deploy different reasoning strategies such as backward reasoning. The process can be deliberate or completely unintentional.
    1. A clinician employing “hypothesis-driven reasoning” (“working backwards”) starts with a clinical problem, generates a series of hypotheses about the patient’s illness, then tests each of these against the available clinical data. It is a time and effort consuming process.
    2. How rigorously one deploys such a strategy is often not dependent on the person’s actual expertise but rather their perceived familiarity of the problem. “Cognitive ease” refers to the phenomenon when we face a common diagnosis or symptom, the impression of familiarity can create a false sense of ease, which makes us more susceptible to diagnostic errors.
  4. Adaptive expertise entails someone’s ability to use existing clinical knowledge structures to come up with a novel solution when they face a complex, unfamiliar problem. An adaptive expert tends to have a solid knowledge structure of their own domain, is not satisfied by complacency, and is cognitively ready to brace novel knowledge in an unknown territory.

References

Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Unravelling the polyphony in clinical reasoning research in medical education. J Eval Clin Pract. 2021;27(2):438-450. doi:10.1111/jep.13432

Endsley MR. Toward a Theory of Situation Awareness in Dynamic Systems. Human Factors. 1995;37(1):32-64. doi:10.1518/001872095779049543

Endsley MR. Situation Awareness Misconceptions and Misunderstandings. Journal of Cognitive Engineering and Decision Making. 2015;9(1):4-32. doi:10.1177/1555343415572631

Durning S, Artino AR Jr, Pangaro L, van der Vleuten CP, Schuwirth L. Context and clinical reasoning: understanding the perspective of the expert's voice. Med Educ. 2011;45(9):927-938. doi:10.1111/j.1365-2923.2011.04053.x

Durning SJ, Artino AR, Boulet JR, Dorrance K, van der Vleuten C, Schuwirth L. The impact of selected contextual factors on experts' clinical reasoning performance (does context impact clinical reasoning performance in experts?). Adv Health Sci Educ Theory Pract. 2012;17(1):65-79. doi:10.1007/s10459-011-9294-3

Arocha JF, Wang D, Patel VL. Identifying reasoning strategies in medical decision making: a methodological guide. J Biomed Inform. 2005;38(2):154-171. doi:10.1016/j.jbi.2005.02.001

Mamede S, Schmidt HG, Rikers RM, Penaforte JC, Coelho-Filho JM. Breaking down automaticity: case ambiguity and the shift to reflective approaches in clinical reasoning. Med Educ. 2007;41(12):1185-1192. doi:10.1111/j.1365-2923.2007.02921.x

Carbonell KB, van Merrienboer JJG. Chapter 12: Adaptive Expertise. In: Ward P, Schraagen JM, Gore J and Roth EM, ed. The Oxford Handbook of Expertise. Oxford University Press, 2018. DOI: 10.1093/oxfordhb/9780198795872.001.0001

Croskerry P. Adaptive expertise in medical decision making. Med Teach. 2018;40(8):803-808. doi:10.1080/0142159X.2018.1484898

McBee E, Ratcliffe T, Schuwirth L, et al. Context and clinical reasoning : Understanding the medical student perspective. Perspect Med Educ. 2018;7(4):256-263. doi:10.1007/s40037-018-0417-x

Sandhu G, Ramaiyah S, Chan G, Meisels I. Pathophysiology and management of preeclampsia-associated severe hyponatremia. Am J Kidney Dis. 2010;55(3):599-603. doi:10.1053/j.ajkd.2009.09.027

Pu Y, Wang X, Bu H, Zhang W, Lu R, Zhang S. Severe hyponatremia in preeclampsia: a case report and review of the literature. Arch Gynecol Obstet. 2021;303(4):925-931. doi:10.1007/s00404-020-05823-9

Rotem R, Bilitzky A, Abady Nezer T, Plakht I, Weintraub AY. Clinical and laboratory markers in the recovery from severe preeclampsia. Pregnancy Hypertens. 2017;8:46-50. doi:10.1016/j.preghy.2017.03.003

Mylopoulos, M, Kulasegaram, K, Woods, NN. Developing the experts we need: Fostering adaptive expertise through education. J Eval Clin Pract. 2018; 24: 674– 677. https://doi-org.ezproxy.med.nyu.edu/10.1111/jep.12905

 

Contributors

John Hwang, MD - Author / Host

Cindy Fang, MD - Author / Host

Aron Mednick, MD - Author / Expert discussant

Shreya Trivedi, MD - Author / Producer

Reviewers

Sean Burke, MD

Vickie Kassapidis, MD

Those named above, unless otherwise indicated, have no relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Release Date: January 28, 2022

Expiration Date: January 28, 2025

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and Core IM.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates each enduring material (podcast) for .75 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to .75 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How to Claim CME Credit and MOC Points

After listening to the podcast, complete a brief multiple-choice question quiz.  To claim CME credit and MOC points you must achieve a minimum passing score of 66%.  You may take the quiz multiple times to achieve a passing score.