The genealogy of teaching clinical reasoning and diagnostic skill: the GEL Study

The genealogy of graduate medical education in America begins at the bedside. However, today’s graduate medical trainees work in a training environment that is vastly different from medical training a century ago. The goal of the Graduate Medical Education Laboratory (GEL) Study, supported by the American Medical Association’s (AMA) “Reimagining Residency” initiative, is to determine the factors in the training environment that most contribute to resident well-being and developing diagnostic skills. We believe that increasing time at the bedside will improve clinical skill, increase professional fulfillment, and reduce workplace burnout. Our graduate medical education laboratory will test these ideas to understand which interventions can be shared among all training programs. Through the GEL Study, we aim to ensure resident readiness for practice as we understand, then optimize, the learning environment for trainees and staff.

Understanding Doctor Decision Making: The Case of Depression Treatment

Treatment for depression is complex, requiring decisions that may involve trade‐offs between exploiting treatments with the highest expected value and experimenting with treatments with higher possible payoffs. Using patient claims data, we show that among skilled doctors, using a broader portfolio of drugs predicts better patient outcomes, except in cases where doctors' decisions violate loose professional guidelines. We introduce a behavioral model of decision making guided by our empirical observations. The model's novel feature is that the trade‐off between exploitation and experimentation depends on the doctor's diagnostic skill. The model predicts that higher diagnostic skill leads to greater diversity in drug choice and better matching of drugs to patients even among doctors with the same initial beliefs regarding drug effectiveness. Consistent with the finding that guideline violations predict poorer patient outcomes, simulations of the model suggest that increasing the number of possible drug choices can lower performance.

Can Surgical Registrars Accurately Identify the Urgent from the Non-Urgent Patient Presenting with Acute Abdominal Pain?

Background: Acute abdominal pain is a common surgical presentation with a wide range of causes. Differentiating urgent patients from non-urgent patients is important to optimise patient outcomes and the use of hospital resources. The aim of this study was to determine how accurately urgent and non-urgent patients presenting with abdominal pain can be identified. Methods: A prospective study of consecutive patients admitted with abdominal pain was undertaken. Urgent patients were classified as requiring treatment (theatre, intensive care unit, endoscopy, or radiologic drainage) within 24 h. Differentiation between urgent and non-urgent was made on the basis of the initial assessment prior to the use of advanced imaging. Outcomes were compared to a final classification based on final diagnosis as adjudicated by an expert panel. Results: Of the 301 patients included, 93 (30.9%) were deemed urgent based on initial assessment, compared to 83 (27.6%) on final diagnosis. Overall sensitivity for recognising urgent patients was 74.7% and specificity 89.9%, and overall accuracy was higher for senior registrars compared to junior registrars (p = 0.015). Urgent patients more often looked unwell or had peritonism on examination (39.8 vs. 17.4% and 56.6 vs. 14.7%, respectively, p < 0.001 for both). Conclusions: Registrars can accurately differentiate urgent from non-urgent patients with acute abdominal pain in the majority of cases. Accuracy was higher amongst senior registrars. The “end-of-the-bed-o-gram” and clinical examination are the most important features used for making this differentiation. This demonstrates that there is no substitute for exposure to acute presentations to improve a trainee’s diagnostic skill.

Identifying error types in visual diagnostic skill assessment

Background:Misinterpretation of medical images is an important source of diagnostic error. Errors can occur in different phases of the diagnostic process. Insight in the error types made by learners is crucial for training and giving effective feedback. Most diagnostic skill tests however penalize diagnostic mistakes without an eye for the diagnostic process and the type of error. A radiology test with stepwise reasoning questions was used to distinguish error types in the visual diagnostic process. We evaluated the additional value of a stepwise question-format, in comparison with only diagnostic questions in radiology tests.Methods:Medical students in a radiology elective (n=109) took a radiology test including 11–13 cases in stepwise question-format: marking an abnormality, describing the abnormality and giving a diagnosis. Errors were coded by two independent researchers as perception, analysis, diagnosis, or undefined. Erroneous cases were further evaluated for the presence of latent errors or partial knowledge. Inter-rater reliabilities and percentages of cases with latent errors and partial knowledge were calculated.Results:The stepwise question-format procedure applied to 1351 cases completed by 109 medical students revealed 828 errors. Mean inter-rater reliability of error type coding was Cohen’s κ=0.79. Six hundred and fifty errors (79%) could be coded as perception, analysis or diagnosis errors. The stepwise question-format revealed latent errors in 9% and partial knowledge in 18% of cases.Conclusions:A stepwise question-format can reliably distinguish error types in the visual diagnostic process, and reveals latent errors and partial knowledge.

Peripheral Blood Smear Utilization within a Military Hematology/Oncology Fellowship Program

Background: The practice of peripheral blood smear (PBS) interpretation is considered an important diagnostic skill in Hematology/Oncology (HO). The Accreditation Council of Graduate Medical Education (ACGME) requires trainees to become proficient in the preparation and interpretation of blood smears. We explored practice patterns of PBS utilization in a tertiary care, military medical center HO fellowship program. Methods: A retrospective chart review was conducted on 350 consecutive outpatient referrals for benign hematology diagnoses (ICD-9 codes 280-289) in a military medical center, from August 2011 to March 2012. Data obtained from the electronic medical records (EMR) included patient demographics, pertinent medical history, labs ordered, and provider status (resident, fellow, or staff). We also recorded HO ordering patterns for complete blood counts (CBC) and PBS and documentation of PBS findings. For those encounters in which the findings were documented, we reported any further diagnostic studies ordered. The practices of PBS review by HO clinicians and hematopathologists (HP) were also compared. Results: 334 of 350 records reviewed met inclusion criteria for the study. Of the 16 records excluded, one was due to age > 85, 11 due to malignant oncology diagnoses, and 4 were unavailable within the EMR. The median age was 52.5 with males representing 52% of the cohort. 43.8% were self-reported as Caucasian, 23.6% African-American, and 32.6% “Other.” The distribution of diagnoses were 52.7% (n = 176) erythrocyte (RBC) disorders, 23.0% (n = 77) leukocyte (WBC) disorders, 10.2% (n = 34) platelet (PLT) disorders, and 14.1% (n = 47) falling into the category of “other.” The five most common diagnoses were anemia, unspecified (n = 74, 19.3%), iron deficiency anemia (n = 53, 13.8%), leukocytosis, unspecified (n = 37, 9.6%), thrombocytopenia, unspecified (n = 31, 8.1%), and leukopenia, unspecified (n = 16, 4.2%) corresponding to ICD-9 codes 285.9, 280.9, 288.6, 287.5, and 288.5, respectively. A CBC was ordered in 82.9% encounters (n = 277/334, 95% confidence interval [CI], 78.9%-87%) A PBS was ordered in 52.3% of cases in which a CBC was ordered (n = 145/277, 95% CI, p < 0.001). There was no statistical significance between the rates at which residents, fellows, or staff ordered PBS with percentages of 40% (n = 18/45), 43.6% (n = 89/204), and 44.7% (n = 38/85), respectively. A HP reviewed 5.7% (n=19/334) of the CBC’s obtained. If a PBS was ordered, findings were documented in the EMR for 49% of cases (71/145). In the 71 encounters that had PBS documentation, only 7 had HP review (9.9%). Examination of PBS led to further evaluation in 40.8% (29/71) of cases, which represented 8.7% (29/334) of the entire cohort. Of these 29, there was one consult to Gastroenterology, one imaging study ordered (ultrasound for splenomegaly), 9 bone marrow biopsies (12.7%), and lab work in all 29. Of the labs ordered, 8 (27.6%) were studies for hemolysis (DAT, LDH, haptoglobin), 10 (34.5%) were studies for myeloproliferative disease (Jak2, BCR-ABL), and 5 (17.2%) were peripheral flow cytometry. A PBS was more likely to be ordered for WBC disorders (71.9%, CI 95%: 61.9%-81.9%; p ≤ 0.001), followed by PLT (61.3%, CI 95%: 44.2%-78.4%; p = 0.076) and RBC disorders (38.7%, CI 95%: 30.9%-46.5%; p ≤ 0.001), respectively. Of the 29 cases in which PBS findings were documented and further studies ordered, 8 (27.6%) were RBC disorders, 10 (34.5%) were WBC disorders, 6 (20.7%) were PLT disorders, and 5 (17.2%) fell into the category of “other.” In the “other” category, 2 were other specified disease of blood and blood-forming organs (289.89), and the remaining 3 were splenomegaly (789.2) polyclonal hypergammaglobulinemia (273), and monoclonal paraproteinemia (273.1). Discussion: The practice of interpreting the PBS is considered an important diagnostic skill for HO providers. In a military HO training program, PBS were ordered in about half of new benign hematologic outpatient referrals. When PBS were ordered, findings were documented in 49% of cases. While diagnoses could be made without getting PBS in a majority of cases, close to 10% of all benign hematology referrals had documented PBS fidings that led to further diagnostic evaluation. Disclosures No relevant conflicts of interest to declare.