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#45 Clinical Reasoning Remediation With Sarah Vick, MD

July 10, 2024 | By

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Join us as Dr Sarah Vick @SVickMD shares practical techniques and frameworks from her workshop at AIMW24 on helping diagnose and treat clinical reasoning gaps in your learners.  We break down clinical reasoning into actionable steps; you’ll come away with helpful tips you can take back to clinic or wards next time you are teaching!

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Meet our Guest:

Sarah Vick, MD  is originally from Evansville, Indiana and completed her medical degree at Indiana University School of Medicine. She completed her Internal Medicine residency and chief year at the University of Kentucky. She stayed on faculty at UK as an academic hospitalist where she is currently one of the Associate Program Directors.

Show Segments

0:00 Intro, disclaimer, guest bio, Picks of the Week

6:48 Case from Kashlack, Defining clinical reasoning 

10:42 Pyramid Framework for assessing clinical reasoning skills

16:13 Systems 1 vs system 2 thinking

18:21 Problems with hypothesis generation- diagnosis and treatment

26:16 Problems with premature closure- diagnosis and treatment

28:31 React Framework

29:50 Problem Representation

31:50 IDEA Framework

35:52 Synthesis/Illness Scripts

40:36 Teaching clinical reasoning explicitly

42:54 When to escalate or pass on to next attending

47:30 Management plans/equity check

52:20 Outro


Clinical Reasoning Remediation Pearls

  1. Clinical reasoning remediation is hard, but rewarding. Being able to observe what your learner is doing and attach behaviors to specific domains will help you target a remediation strategy that’s tailored to their needs. 
  2. Use Dr Vick and Dr Wolak’s Clinical Reasoning Pyramid to break down clinical reasoning steps.  This pyramid starts with foundational skills at the bottom and moves up to higher orders of clinical reasoning: Hypothesis Generation, Premature Closure, Prioritization, Synthesizing, and Management Plan.
  3. Use REACT (Rapid Evaluation Assessment of Clinical Reasoning Tool) in direct observation of learners, this includes five domains: Collecting, Interpreting, Managing, Communicating, and Reflecting to determine where a learner is in their clinical reasoning process.
  4. Use the IDEA framework for reviewing documentation to assess clinical reasoning.  It includes: Interpretive summary, Differential Diagnosis, Explaining the reasoning in choosing the leading diagnosis, and Alternative diagnosis.
  5. Use techniques like Role-play to solidify hypothesis generation. “Buy a Qualifier Game,” One Minute Preceptor, or SNAPPS can help with prioritization.  Creating a table to compare and contrast key features of diagnoses can solidify illness scripts and synthesis skills.  Discuss contingencies and expected outcomes to help learners work on management plans.

Clinical Reasoning Remediation Notes 

Defining Clinical Reasoning

Clinical reasoning is the process of collecting clinical data including patient history and exam, building this into an accurate problem representation, and then using illness scripts or schemas to form a differential diagnosis.  At its core, clinical reasoning is about thinking through a patient presentation and all of the elements to get to that differential and diagnosis (Bowman 2006).

The Curbsiders has a great episode on Clinical Reasoning if you want to dive more into the basics.

Approaching Clinical Reasoning 

Pyramid Framework

Clinical reasoning is complex, so as an educator, when you hear a trainee giving a presentation that seems to be missing details or jumping to incorrect conclusions, Dr Vick recommends encouraging the learner to share more of their thought process so you can try to see where the problem lies.  Can they gather a detailed history, but then aren’t able to put those pieces together in a way that is meaningful?  Can they generate a hypothesis based on the chief complaint? Is there anchoring  or recall bias?  Are they having trouble prioritizing a differential?  Can they synthesize the information and draw on illness scripts reasonably? 

Dr Vick highlights that there are many frameworks for clinical reasoning in the literature.  She created a framework with her colleague, Dr Megan Wolak, which they presented at the Alliance for Academic Internal Medicine AIMW 2024, to break down clinical reasoning steps.  This pyramid structure starts with skills at the bottom that are the most essential, moving up to higher orders of clinical reasoning: Hypothesis Generation, Premature Closure, Prioritization, Synthesizing, and Management Plan.

Hypothesis Generation

The base of the pyramid is hypothesis generation.  For hypothesis generation to be effective, we have to cognitively engage with it, considering aspects such as the patient’s demographics, what is common in the practice setting, and what fits with the patient’s specific presentation.   It involves knowing the right questions to ask, and not just relying on checklists.   

Dr Vick recommends direct observation as one of the most useful ways to see the process of hypothesis generation- watch how the learner is asking questions. What is their approach to gathering information? Are they going through a checklist, are they organized in a different way, or is it unclear what the connections are between their questions/they’re disorganized)?  Documentation review can be helpful: did the learner explain in their note why they decided on this diagnosis versus another?  What history and exam did they feel was pertinent to document and how did they put those pieces together? 

If an educator feels the learner needs help with hypothesis generation, Dr Vick suggests a remediation prescription could include role-play.  The educator can play a patient (knowing what the diagnosis is) and have the learner take a history and then outline what key features of the physical exam they would be looking for.  The process of seeing how the learner would gather data and then what they would do with it is a really rich way to help with hypothesis generation.  Direct observation or documentation review with feedback can be very helpful, as real life encounters help learners invest in the process (Kalet 2014).

Premature Closure

The second level up is premature closure.   This step involves checking understanding before the learner finalizes ideas, avoiding recall bias or anchoring (Croskerry 2003).  Asking about thought processes and watching in the room can be helpful as an educator to understand how the learner has made the clinical reasoning decision. 

The key to avoiding premature closure is helping the learner recognize the importance of examining their thinking.  Dr Vick likes to call a diagnostic timeout.  Consider, what else could this be? Are there other features that we are not incorporating, or maybe ignoring, that do not fit with the initial diagnosis?  Dr Vick recommends as educators we should role model avoiding premature closure by naming instances where things are not going as expected or being open about missing an initial diagnosis.  

Prioritization

The next step up is prioritization.  This step involves having the knowledge of discriminating features between different diagnoses to identify which is most likely.  An educator should listen for the learner to explain discriminating features and be able to understand which aspects of the history/exam go together and which should be split into separate problems, for example is the learner describing problem 1, fever… problem 2, right upper quadrant pain… problem 3, jaundice…. With separate differentials for each?  Or is the learner able to see that (and to integrate) these can be one unified problem?

To successfully prioritize, the learner needs an accurate problem representation which includes the most salient features related to the differential diagnosis list that they’re about to generate.  Make sure the learner appreciates the importance of semantic qualifiers, ie acute versus chronic or unilateral vs bilateral, and how these can change their differential diagnosis list (Bowen 2017).  When someone is struggling in this domain, Dr Vick recommends the “Buy a Qualifier” game where the learner gets to pick two qualifiers that they think are the most essential to creating this differential, for example, acute + unilateral.  Then talk through why they picked those and how changing them would impact the differential.  Using formats like the One Minute Preceptor or SNAPPS  to assist learners in reflecting on their thinking while precepting can help too (check out our Episode #12 for more on these models). 

Synthesis

Then comes synthesis, or “seeing the big picture”.  The learner has gathered the data and made a prioritized differential, then they have to put those pieces together in a way that makes sense.  

Synthesis involves comparing illness scripts.  An educator can see that a learner might be struggling with their illness scripts primarily by listening to them recognizing and identifying key features, and having them talk through how new data (i.e. an additional test result) can help refine their most likely diagnosis.

Dr Vick likes to help learners solidify synthesis skills by creating a chart of your most likely diagnoses A, B, C, D, E, across the top.  And then on the side, having what are the demographics you would expect in this particular case, what are the key features, what are the exam findings, what are the laboratory findings you would expect.  Then have the learner fill in the grid for all of the diagnoses.  Dr Vick will then hand the learner a case that’s clearly one of these (A,B,C…), and their job is then, based on their sheet, to highlight the features that are present to identify the diagnosis.  Writing it down makes it tangible and hammers home that illness scripts are about comparing and contrasting what’s present and what’s not (ten Cate 2018).

Management Plans

The last piece, the capstone on the pyramid, is management plans.  Here the educator is looking for the learner to demonstrate specific, appropriate, patient centered, and evidence based plans.   Check out our episode on Teaching Management Reasoning for more information on building and assessing skills in this domain.

If a learner has identified what is likely the correct diagnosis, Dr Vick encourages the learner to reflect on the expected course and delineate a concrete contingency plan for next steps.

Consider an equity check here.  Considering particular social determinants of health or certain patient demographics is part of the management plan discussion.  Dr Vick likes to acknowledge sometimes these situations can be really hard.   The more we highlight what we can do as physicians, it can empower our learners to continue to address particular nuances (Abdoler 2022). 

System 1 vs System 2 Thinking

System 1 thinking is intuitive, using pattern recognition to make a diagnosis.  Quick thinking is more prone to cognitive errors, so in clinical reasoning, system one thinking is where premature closure or metacognitive biases come in.

System 2 thinking is the more methodical, slow process.  This is involved when actively considering how to organize information–putting pieces together in that synthesis category- lumping or splitting?  Focusing on key issues/ignoring less important, pulling the right illness scripts (Norman 2009).

Dr Vick recommends as an educator listening for both types of thinking as they are inherent in any type of clinical reasoning.

Frameworks for Identifying Areas for Growth in Clinical Reasoning

These are accessible frameworks that are easy to incorporate into clinical teaching.  Using these for a single observation does not take a lot of time and can help diagnose and treat areas for growth. 

REACT (Rapid Evaluation Assessment of Clinical Reasoning tool): is a framework helpful in direct observation which  includes five domains: Collecting, Interpreting, Managing, Communicating, and Reflecting each of which has specific anchors that can help you determine where a learner is in their clinical reasoning process.  You can print out a copy and go through it step by step during an observation with a learner (Peterson 2022).

IDEA is a helpful framework for reviewing documentation to assess clinical reasoning, which includes specific descriptive prompts and anchors.  

Interpretive summary, clear statement of problem representation including key features, pertinent negatives, semantic qualifiers.

Differential Diagnosis, with commitment on the most likely.

Explaining the reasoning in choosing the leading diagnosis.

Alternative diagnosis with explanations in the reasoning (Schaye 2022).

Learner with Multiple Deficits in Clinical Reasoning

Dr Vick recommends, the most important thing is to start with foundational skills at the lowest level of the pyramid, and until they have accomplished these with reasonable consistency, it’s really hard to move up the pyramid.  If this is a consistent pattern that a learner is struggling in many domains, it can be helpful to call in reinforcements and consider a more formal remediation plan.  Many touches and many meetings, ideally with people with expertise in teaching these skills, like clinical reasoning coaches, as well as their program director or associate program director and advisor can be helpful.  Dr Vick’s program teaches these learners to be able to say, “ I am working on this particular skill.  I would like you as my attending this week to provide me feedback on this domain” to carry that learning across settings.   This takes time.  

Passing on a Learner Signout to the next Attending or Escalating Higher

Dr Vick likes to give learner signoff to the next attending taking over her team, explaining what she has given them feedback on and what areas of clinical reasoning in which the learner struggles.   She outlines the things that she has been working on with them, and encourages the next attending to continue this forward.  This can help maintain consistent feedback messages from different attendings.   Especially when you have learners that are early on in their training, we have so much time with them and so much ability to give them feedback and help grow these skills (Shaw 2023).

She recommends considering escalating concerns if a learner is not receptive to the feedback or if concerns are in multiple domains or she’s concerned about patient safety.

Take home points:

Clinical reasoning remediation is hard, but rewarding.   Being able to observe what your learner is doing and attach behaviors to specific domains will help you target a remediation strategy that’s tailored to their needs.  Whatever frameworks you use to help learners improve is value added.


Links

  1. Twice as Hard book by Jasmine Brown
  2. Era’s pick: Waxahatchee band

Goal

Listeners will develop skills to diagnose and address the domain issue for a learner struggling with the clinical reasoning process.

Learning objectives

After listening to this episode listeners will…

  1. Diagnose the clinical reasoning domain of concern 
  2. Develop remediation strategies based on the particular domain in which the learner is struggling 
  3. Recognize a novel remediation framework for clinical reasoning that can be employed with struggling learners

Disclosures

Dr Vick reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Heublein M, Kryzhanovskaya E, Vick S, Pahwa A.  #45 Clinical Reasoning Remediation. The Curbsiders Teach Podcast. https://thecurbsiders.com/teach. July 10, 2024.   

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Episode Credits

Script: Era Kryzhanovska MD
Show Notes/CME/Infographic/Cover Art: Molly Heublein MD
Hosts/Editors: Era Kryzhanovskaya MD, Molly Heublein MD
Peer Reviewer: Amit Pahwa, MD
Guest: Sarah Vick MD
Technical support: Podpaste
Theme Music: MorsyMusic

CME Partner

vcuhealth

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

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