Hoofbeats: Struggles with Clinical Reasoning

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• When evaluating a struggling learner, first ensure their challenges are not due to an unmet need related to mental well-being, their personal life, or a problematic learning environment. According to one study, around 40% of struggling learners are grappling with an underlying mental wellbeing issue, frequently anxiety, depression, or ADHD. (Warburton & Shahane, 2020).
  1. Mental health screening both helps residents seek appropriate treatment from their program’s designated mental health professional, and better enables them to progress with clinical coaching.
• Second, perform a “global assessment” to identify the domain(s) that are contributing most to the learner’s difficult.
  • Review standardized assessments and observe the learner directly, evaluating them across four domains:
    • Medical knowledge
    • Clinical reasoning
    • Organization & efficiency
    • Professionalism & communication
  • Although most struggling learners are presumed to have medical knowledge deficits, the most common primary deficits are in clinical reasoning and organization & efficiency. 
  • Initial feedback to residents should be “low-inference,” focused on concrete observations / behaviors, rather than “high-inference,” which includes conclusions about those behaviors.
• Third, for learners who seem to be struggling somewhere along the clinical reasoning pathway, try to identify which step the learner is struggling with the most
  • Steps for clinical reasoning (Cavet: in practice, this is an iterative process): 
    • Generate hypotheses → gather data → create a problem representation → refine hypotheses → select a working diagnosis
• Case 1: Hypothesis-driven data gathering
  • Definition: using diagnostic hypotheses to keep obtained information focused and appropriately thorough, which improves diagnostic accuracy.
  • Possible manifestations of deficit: Excessive or indiscriminate collection, reporting, and/or documentation of information (which may appear as disorganization and inefficiency); Alternately, absence of relevant data gathering despite appropriate knowledge base.
  • Coaching Exercise 1, “Searching for the scripts”: 
    • Provide the learner a chief complaint, ask them for a tiered differential, then ask them to choose only five pieces of historical information and five physical exam findings to distinguish between the diagnoses they’re considering (Parsons et al, 2020).
  • Coaching Exercise 2, “Findings That Matter” AKA highlighting key features:
    • Provide the learner a printed history and physical and ask them to highlight only the information they believe is most relevant for building and narrowing their differential.
• Case 2: Problem representation
  • Definition: creating a “one-liner” that effectively pulls all the most relevant information together and drives the differential diagnosis (e.g. by triggering appropriate illness scripts).
  • Possible manifestations of deficit: Struggling with multiple forms of clinician communication (e.g. handoffs, consults, oral presentations) and appearing to “miss the big picture”
  • Coaching Exercise 3, “Problem Representation Breakdown”: 
    • Deconstruct the problem representation into its three primary components-- patient demographics and risk factors, temporal pattern expressed using semantic qualifiers, and key symptoms and findings.
  • Coaching Exercise 4, “Role Reversal”: 
    • Ask the learner to role play as a new patient presenting with a common condition, through which they may reveal features of their illness script for that disease.
• Case 3: Hypothesis generation
  • Definition: the ability to generate a wide differential based on limited information.
  • Possible manifestations of deficit: narrow differential diagnoses, delayed response to new concerns, or acting inappropriately during time-sensitive scenarios like codes. 
  • Coaching Exercise 5, “Triage”: 
    • Ask the learner to assign an urgency level, from 1 to 10, to all the patients on their list or all the calls they received in a given day.
  • Coaching Exercise 6, “Scaffolding”: 
    • Encourage the learner to develop frameworks for common and uncommon chief complaints using physiology, epidemiology, severity, etc.

Contributors

Jess Dreicer, MD - Author, Host

Aaron Troy, MPH - Author, Producer

Andrew Parsons, MD - Author, Expert discussant

Karen Warburton, MD - Author, Expert discussant

Shreya Trivedi, MD - Author

Marty Fried, MD - Author

Vickie Kassapidis, MD - Author, Producer

Zaven Sargsyan, MD - Author, Host

Reviewers

Denise M. Connor, MD

Andrew Olson, MD

Those named above unless otherwise indicated have no relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Release Date:  December 9, 2020

Expiration Date: December 9, 2023

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 the 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 0.75 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 0.75 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.