Conferences and Teaching

Applying Structural Analysis to Clinical Presentations: Strategies for Embedding Structural Competency into Clinical Reasoning and Teaching

Iman Hassan, MD MS; Thuy Bui, MD; Shwetha Iyer, MD; Eloho Ufomata, MD MS; Snehal Patel, MD

Structural and social determinants of health account for the health disparities we see along social hierarchies, and their impact has been made more evident by the recent COVID-19 pandemic. There have been increasing calls to incorporate structural competency into medical education. The structural and social context, however, has yet to be fully integrated into everyday clinical practice and little has been published on how to concretely imbed structural competency into clinical reasoning. We will provide a framework for structural analysis, which incorporates four key steps: (1) developing a prioritized clinical problem list, (2) identifying social and structural root causes for clinical problems, (3) constructing and documenting a prioritized structural problem list, and (4) brainstorming solutions to address structural barriers and social needs. During this workshop, we will show how structural analysis can be used to operationalize structural reasoning into everyday inpatient and outpatient clinical assessments. We will offer participants the opportunity to apply structural analysis to clinical scenarios in small groups using tools that we have developed. We will also discuss benefits and challenges of using structural analysis and illustrate the applications of structural analysis in undergraduate and graduate medical education at our respective institutions. For more information, please contact Dr. Thuy Bui (buit@upmc.edu).

The Clinical Reasoning Case Conference:  Use of Principles from Example-Based Learning in a Conference Format

Deborah DiNardo MD, MS; Eliana Bonifacino, MD MS; Sarah Tilstra MD MS

While components of clinical reasoning are infused into standard residency education, explicit instruction regarding these principles is often lacking. Trainees may be expected to intuit the reasoning processes used by their clinical teachers. The quality of this learning experience can be highly variable when a common language for discussion of clinical reasoning principles does not exist, and when clinical teachers lack the skills to make their reasoning processes explicit.  Traditional “unknown case conferences” are sometimes used to teach clinical reasoning.  However, these tend to focus on the ability of an expert discussant to reach a difficult or unusual diagnosis, often without an explicit focus on clinical reasoning principles that can be applied more broadly by learners. In our case-based interactive conference series, a focus on the clinical reasoning process and on potential for cognitive bias has contributed to the development of a shared clinical reasoning vocabulary within our program and to the dissemination of clinical reasoning skills. During this workshop, we will introduce our “Clinical Reasoning Case Conference,” which includes sequential delivery of clinical information from a real patient case to an expert discussant, who in turn describes their approach to the unknown case in a “think-out-loud” format. The conference is facilitated by faculty member with expertise in clinical reasoning, who, in keeping with principles from example-based learning, provides explicit commentary regarding the clinical reasoning processes being used. This interactive workshop will provide attendees with a framework for developing a clinical reasoning case conference at their own institution. For more information, please contact Dr. Deborah DiNardo (deborah.dinardo@va.gov).

Diagnosing the Misdiagnosis: A Medical Educator’s Guide to Identification and Real-Time Remediation of Clinical Reasoning Missteps

Deborah DiNardo MD MS; Eliana Bonifacino, MD MS; Casey McQuade, MD MS; Sarah Tilstra MD MS

In their recent report “Improving Diagnosis in Health Care,” the Institute of Medicine identified diagnostic error as an important contributor to adverse patient outcomes and highlighted the urgent need for better training in decision-making across all medical disciplines. Within internal medicine, retrospective investigations have suggested that flaws in the clinical reasoning process, not deficits in knowledge, are to blame in most cases of diagnostic error. Medical educators must be able to appropriately identify and remediate clinical reasoning missteps to train residents to become better decision-makers. This workshop will provide attendees with a framework for “diagnosing” learner missteps in the clinical reasoning process along with practical tips for remediating commonly encountered cognitive errors. In particular, we will introduce the six steps of the clinical reasoning process, as described by Trowbridge et al in ACP’s “Teaching Clinical Reasoning,” any of which can be prone to cognitive error.  Participants will subsequently review real clinical scenarios in small break-out groups, using the presented framework to “diagnose” the learner’s cognitive error (with identification of specific cognitive biases) and to suggest strategies for remediation.  Provided scenarios will highlight commonly encountered clinical reasoning pitfalls. The workshop will conclude with a large group debrief of strategies for remediation of each case. Presenters will also share pearls from our own institutional experiences in establishing a clinical reasoning culture, where education about and remediation of the diagnostic process has become a programmatic priority. For more information, please contact Dr. Deborah DiNardo (deborah.dinardo@va.gov).

Turning Experience into Expertise: Habits for Life-Long Development of Clinical Reasoning Skills

Casey McQuade, MD MS; Eliana Bonifacino, MD MS; Katie Gavinski, MD MS; Deborah DiNardo MD MS

Developing excellent clinical reasoning is a cornerstone of improving diagnosis. Trainees spend much of their time honing this skill and finish their training ostensibly competent at solving clinical problems. However, despite this promise of competent graduates from medical training programs, the rate of diagnostic errors has remained unacceptably high. Research from other fields shows that experience alone does not produce true expertise but leads to “experienced nonexperts,” whose skill acquisition plateaus. The development of true diagnostic expertise instead takes a total of 10 years or nearly 10,000 hours of deliberate practice to achieve. To continue improving diagnosis in medicine, health care professionals (and medical educators, for their trainees) must know how to transition from experience-based competence to the continuing development of expertise in diagnosis throughout a career.  

The goal of this workshop is to teach participants how to develop their own expertise in clinical reasoning over time. While the focus will be on the development of strategies for individual health care professionals, the topics covered easily can be applied by medical educators to training programs or by professionals looking to enhance the continuing education of their colleagues. For more information, please contact Dr. Casey McQuade (mcquadec@upmc.edu).

#TwitterReport: Using Twitter to Teach Clinical Reasoning to Trainees

Casey McQuade, MD MS; Michael Simonson, MD MS, Hafiz Qurashi, MD; Amar Kohli, MD MS

Most training programs use a form of case-based tutorial – termed “resident report” or “morning report” – to teach clinical reasoning to their trainees. The key feature of these case conferences is their interactivity. Changes in duty hours and increasing clinical demands present a barrier to consistent resident attendance of longform teaching sessions. As a result, many trainees supplement their training with asynchronous learning from podcasts, question banks, or additional didactic curricula. These modalities lack interactivity and often require time comments which mirror those of in-person didactics.

Social media (SoMe) is increasingly used by physicians and other health professionals for asynchronous medical education. Twitter, a microblogging platform with a maximum of 280 characters per post (per “tweet”), has emerged as the dominant platform for SoMe-based education in recent years. Education on Twitter is versatile in form, ranging from single-question quizzes or picture-based questions to longer topic-based tutorial threads (“tweetorials”). Each of these forms retains interactivity and provides educational pearls that can be consumed asynchronously in less than 5 minutes. During this workshop, we will cover strategies for adapting longform clinical reasoning education into shorter, bite-sized teaching episodes that can be disseminated easily on social media. This workshop will also provide attendees with a framework for developing educational content on Twitter at their own institution. For more information, please contact Dr. Casey McQuade (mcquadec@upmc.edu).