How to Teach “Diagnosis” and  “Patient Management”

By Rob Woods
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(From the EiC:  This guest post is a great example of integrating existing education frameworks into a comprehensive, but easily accessible, SUPER framework.  This is my new go-to approach for teaching  “bedside teaching”… if that makes sense.  At least I hope it does for my medical education fellows!

Jonathan)

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Background:
Teaching clinical reasoning (i.e. diagnosis and patient management) in the acute care environment (e.g. emergency department) has both challenges and opportunities. Typically, junior trainees are not required for patient care, so they can work at a slower pace and select patients that meet their educational needs.  However, for the teacher, such flexibility may not be possible because of
the competing demands of patient care.

This post simplifies the process of teaching a trainee how to diagnose and treat a patient.

Diagnosing your Learner’s Clinical Reasoning Stage:
The competency framework RIME is an easy way to map the trainee’s progression of clinical reasoning.1

  • Reporter – Consistently good in inter-personal skills, reliably obtains and communicates clinical findings
  • Interpreter – Able to prioritize and analyze patient problems
  • Manager – Consistently proposes reasonable options incorporating patient preferences
  • Educator – Consistent level of knowledge of current medical evidence; can critically apply knowledge to specific patients

After reading this elegant framework, you think ‘Great, but what do I do about it?’ Well, think of it like a diagnostic and treatment algorithm for teaching clinical reasoning in the acute care setting!  There are 3 simple tools you can use that map very nicely to the RIME stages of trainee progression.

 

Trainee Symptoms

 

 

RIME Framework Level or Diagnosis

 

Suggested Intervention or Treatment

Disorganized history, physical exam.  Missing details, unable to create reasonable differential diagnosis, often just suggests some random tests  

 

Reporter

 

 

3 Minute Clinical Presentation

Organized H&Ps, but test ordering is inappropriate, can not appropriately rank items in differential diagnosis  

 

Investigator

 

 

One Minute Preceptor

Manages common patient complaints, but needs tips on subtle aspects of management/disposition  

 

Manager

 

 

RAPID

Struggling to teach more junior trainees  

Educator

 

All of the above

 Struggling to Report…the 3 Minute Clinical Presentation:
When you encounter the trainee that presents a patient to you, and you have a hard time following, you probably have a trainee that is struggling with being a REPORTER.  What they need is structure in their patient presentations.  For some trainees this comes naturally, but for many it needs to be made explicit.

The 3-Minute Clinical Presentation is a great guide for giving your junior trainee a framework for how to present patients in the emergency department.2  It focuses on the order of items in the history of present illness, as well as ensures trainees give a summary statement at the end.  The problem assessment forces the trainee to start listing a differential diagnosis and justify it.  It might take one patient encounter to set this expectation for your trainee or it might take several patient encounters.  In either case, it is worth the investment.

The Oral Presentation Outline:

  1. History of present illness
  2. One liner (ID, Chief complaint and RELEVANT PMHx to today’s complaint)
  3. When they were last well (how long ago) & first episode of complaint
  4. Illness progression
  5. Any medical interventions thus far (other visits, tests, treatments)
  6. Why they came today…what is their emergency?
  7. How they are now
  8. TARGETTED Review of Systems (relevant to the chief complaint and DDx)
  9. PERTINENT PMHx, PSHx, SHx, FHx, ALL Medications & Allergies
  10. Physical Exam, starting with vital signs
  11. Summary statement – includes the one-liner and pertinent positives and negatives from HPI, ROS, PHx, PE
  12. Problem Assessment – list your DDx, in order of severity, making note of what evidence supports or does not support the diagnosis in question
  13. Plan – list investigations to confirm or rule out items on your DDx and suggest symptomatic or definitive therapy.

Struggling to Investigate…the One-Minute Preceptor:
So now you are listening to your trainee, and you can follow the case, but their differential diagnosis is off.  Often these trainees list items in a differential, but the order is off, or the likelihood of their differential is off (e.g. chest pain in healthy 21 year old = angina). When you are busy, it is tempting to just decide what the most likely diagnosis is, and take over management from there.  However, if the trainee is not emotionally invested in the decision-making they will not develop their own clinical reasoning.  Missing the teachable moment is the biggest mistake a teacher can make. 3,4

This is an opportunity to give specific feedback for that case on how to shape their illness scripts.  Each time they see that chief complaint, their differential diagnosis will be refined if given appropriate feedback. The one-minute preceptor is a tool that many of our more effective teachers do naturally.  It forces the trainee to commit and justify their plan of action.

One Minute Preceptor Summary:

  1. Get a commitment

– So you think top item on your DDx is a heart attack?

  1. Probe the trainee for supporting evidence

– What makes you think they are having a heart attack?

  1. Teach general rules

– When we approach young patients with chest pain…

  1. Reinforce what was done right

– It’s great that you thought of the most serious causes of chest pain…

  1. Correct errors

– but it’s not very common for young men to have heart attacks.
They are much more likely to have…

Struggling to Manage…the RAPID Approach:
When intermediate and senior trainees diagnose and treat diseases well, but forget the little important things about patient needs and disposition that lead to excellence in overall patient care, they need help with being a manager.

We developed the RAPID mnemonic as a mental checklist to help trainees provide comprehensive care, addressing issues in priority in the ED setting.5 Thanks to the ALiEM team for using our paper as an opportunity for a design challenge.  What resulted is a nice checklist for RAPID:

RAPID1RAPID2

RAPID makes resuscitation a thought in every case, so subtle abnormalities don’t get overlooked.  It makes pain management a priority.  It puts the non-medical needs at the forefront, so they can be incorporated into the management plan. It emphasizes the importance of ED care being episodic, so that discharge planning has education and contingency planning incorporated.  For the resident who has well developed illness scripts, it helps them to be more complete physicians in an efficient way.

Struggling to be an Educator…teach all 3 tools:
When trainees becoming teachers themselves, share these tools with them. It’s that simple.

Summary:
Remember, just because someone is an intermediate level resident, it does not mean they are immune to needing coaching on the 3-minute clinical presentation or the one-minute preceptor.  Conversely, medical students can develop very sound approaches to common presentations, and the RAPID approach is more appropriate for them.  Tailor your clinical reasoning approach to the trainee as well as the specific case they are seeing.

References:

  1. Pangaro L. A New Vocabulary and Other Innovations for Improving Descriptive In-Training Evaluation. Acad Med 1999;74:1203-1207
  1. Davenport et al. The 3-minute Emergency Medicine Medical Student Presentation: A Variation on a Theme. Acad Emerg Med 2008;15:683-687
  1. Thurgur et al. What do Emergency Medicine learners want from their teachers? A multi-centre focus group analysis. Acad Emerg Med 2005;12(9):856-61
  1. Bandiera G et al. Creating effective learning in today’s emergency departments: how accomplished teachers get it done. Ann Emerg Med 2005;45(3)253-61
  1. Woods RA et al. Teaching the RAPID Approach at the start of Emergency Medicine Clerkship: An Evaluation. CJEM 2014;16(4):273-280