Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students.

OBJECTIVES: Explicit education on diagnostic reasoning is underrepresented relative to the burden of diagnostic errors. Medical educators report curricular time is a major barrier to implementing new curricula. The authors propose using concise student-identified educational opportunities -- differential diagnosis and summary statement writing -- to justify curriculum development in diagnostic reasoning. METHODS: Eighteen clerkship and 235 preclinical medical students participated in a 1 h computerized case presentation and facilitated discussion. Students were surveyed on their attitudes toward the case. RESULTS: All 18 (100% response) clerkship students and 121 of the 235 preclinical students completed the survey. Students felt the module was effective and relevant. They proposed medical schools consider longitudinal computerized case presentations as an educational strategy. CONCLUSIONS: A computerized case presentation is a concise instructional strategy to teach critical points in diagnosis to clerkship and preclinical medical students.

Empirical comparison of three assessment instruments of clinical reasoning capability in 230 medical students.

BACKGROUND: Several instruments intend to measure clinical reasoning capability, yet we lack evidence contextualizing their scores. The authors compared three clinical reasoning instruments [Clinical Reasoning Task (CRT), Patient Note Scoring rubric (PNS), and Summary Statement Assessment Rubric (SSAR)] using Messick's convergent validity framework in pre-clinical medical students. Scores were compared to a validated clinical reasoning instrument, Clinical Data Interpretation (CDI). METHOD: Authors administered CDI and the first clinical case to 235 students. Sixteen randomly selected students (four from each CDI quartile) wrote a note on a second clinical case. Each note was scored with CRT, PNS, and SSAR. Final scores were compared to CDI. RESULTS: CDI scores did not significantly correlate with any other instrument. A large, significant correlation between PNS and CRT was seen (r = 0.71; p = 0.002). CONCLUSIONS: None of the tested instruments outperformed the others when using CDI as a standard measure of clinical reasoning. Differing strengths of association between clinical reasoning instruments suggest they each measure different components of the clinical reasoning construct. The large correlation between CRT and PNS scoring suggests areas of novice clinical reasoning capability, which may not be yet captured in CDI or SSAR, which are weighted toward knowledge synthesis and hypothesis testing.

Convergent Validity of a Novel Clinical Reasoning Tool in Clerkship Medical Students: Pilot Study.

Medical student educators have limited tools for standardized clinical reasoning assessment. The clinical reasoning task (CRT) checklist has been shown to identify specific tasks in the diagnostic process among residents and faculty. Authors assessed a novel student think aloud protocol strategy, the CRT, compared with the validated clinical data interpretation (CDI) test in six third-year medical students. The CRT was scored by two independent reviewers (kappa = 0.88). CRT and CDI scores were strongly positively correlated (r = 0.768, p = 0.074, df = 4). CRT provides both a global assessment of clinical reasoning and specific clinical reasoning deficits.

Checking in on check-out: Survey of Learning Priorities in Primary Care Residency Teaching Clinics.

Background: Despite focus on increasing the quality of ambulatory education training, few studies have examined residents' perceptions of learning during case discussions with their preceptors (i.e., "check-out"). The objective of this study was to assess the difference between residents' and preceptors' perceptions of behaviors that should occur during check-out discussions. Methods: We conducted a cross-sectional survey of categorical internal medicine and family medicine residents and preceptors. The survey was distributed electronically and assessed 20 components of the check-out discussion. Results: Of 38 preceptors, 22 (61%) completed the survey. Of 172 residents, 82 (48%) completed the survey. For residents, we identified discrepancies in desired and perceived check-out behaviors. Specifically, utilizing a dependent sample t-test, residents felt that all 20 areas needed additional teaching during check-out (P < 0.05). Preceptors believed that demonstrating physical examination skills in the patient room during check-out was significantly more important than did residents (P = 0.01). Increasing years of preceptor experience did not statistically relate to their valuation of components important to residents. Discussion: Our research highlighted a major deficiency in training in the check-out process, with residents desiring more patient management education in all components. Moreover, faculty and residents do not necessarily agree with what is an important focus in the "teachable moment." Our results serve as a training needs assessment for future faculty development seminars and highlight the need to consider resident learning needs in general.

Statins and Lower Gastrointestinal Conditions: A Retrospective Cohort Study.

Several studies have reported constipation, abdominal pain, or diarrhea as common adverse events for statins. Statins are among the most commonly prescribed medications, and the impact on the prevalence of these conditions was rarely studied as main outcomes. The aim of this study is to determine if statin therapy is associated with constipation, abdominal pain, diarrhea, or colitis. This was a retrospective cohort study using a regional military health care data from October 1, 2003, to March 1, 2012. A propensity score-matched cohort of statin users and nonusers was created based on 82 variables. The primary analysis evaluated the odds ratios of the following diagnoses: constipation, ≥3 encounters for constipation; abdominal pain, ≥3 encounters for abdominal pain; diarrhea, ≥3 encounters for diarrhea; colitis, ≥3 encounters for colitis; and endoscopy of the lower gastrointestinal tract, ≥3 endoscopies of the lower gastrointestinal tract. After propensity score matching of 6342 statin users and 6342 nonusers, there was no statistically significant difference in constipation (OR, 0.96; 95%CI, 0.87-1.05; P = .33), abdominal pain (OR, 0.95; 95%CI, 0.88-1.02; P = .15), or colitis (OR, 1.02; 95%CI, 0.91-1.14; P = .73). However, there was an association between statin therapy and endoscopy of the lower gastrointestinal tract (OR, 1.14; 95%CI, 1.04-1.26; P = .002) and decreased odds of diarrhea (OR, 0.88; 95%CI, 0.80-0.97; P = .01). In this retrospective cohort study, an association between statin therapy and increased likelihood of being diagnosed with lower gastrointestinal conditions could not be demonstrated, contrary to some statins package inserts.