Embedding a longitudinal diagnostic reasoning curriculum in a residency program using a bolus/booster approach.

Background Diagnostic reasoning skills are essential to the practice of medicine, yet longitudinal curricula to teach residents and evaluate performance in this area is lacking. We describe a longitudinal diagnostic reasoning curriculum implemented in a university-based internal medicine residency program and self-evaluation assessment of the curriculum's effectiveness. Methods A longitudinal diagnostic reasoning curriculum (bolus/booster) was developed and implemented in the fall of 2015 at the University of Iowa. R1, R2, and R3 cohorts were taught the "bolus" curriculum at the beginning of each academic year followed by a "booster" component to maintain and build upon diagnostic reasoning skills taught during the "bolus" phase. Self-administered diagnostic thinking inventory (DTI) scores were collected in the spring of pre-curriculum (baseline, 2014-2015) and post-curriculum (2016-2017). Results The overall DTI scores improved in the R1 cohort, although statistically significant differences were not seen with R2s and R3s. In the original DTI categories, R1s improved in both flexibility of thinking and structure of thinking, the R2s improved in structure of thinking and the R3s did not improve in either category. R1s showed improvement in three of the four subcategories - data acquisition, problem representation, and hypothesis generation. The R2s improved in the subcategory of problem representation. R3s showed no improvement in any of the subcategories. The R3 cohort had higher mean scores in all categories but this did not reach statistical significance. Conclusions Our program created and successfully implemented a longitudinal diagnostic reasoning curriculum. DTI scores improved after implementation of a new diagnostic reasoning curriculum, particularly in R1 cohort.

Secret Sarcoma: A Cardiac Mass Disguised as Influenza.

This case presentation discusses an extremely rare diagnosis presenting with common symptoms, attributed to influenza, which were not investigated further when clear cardiac symptoms developed. The patient initially presented with symptoms consistent with influenza, but when orthopnea and dyspnea on exertion developed, these cardiac symptoms continued to be attributed to a postviral syndrome and were not further evaluated. Premature closure bias contributed to a delay in diagnosing a rare cardiac condition. The diagnostic momentum, or the continuing of a diagnostic label, occurred across multiple providers and settings. This case demonstrates the risk of premature closure and diagnostic momentum and reminds clinicians to reframe the differential diagnosis as more information on history or physical exam becomes available.

Portion control for the treatment of obesity in the primary care setting.

BACKGROUND: The increasing prevalence of obesity is a significant health threat and a major public health challenge. A critical need exists to develop and evaluate practical methods for the treatment of obesity in the clinical setting. One of the factors contributing to the obesity epidemic is food portion sizes. Limited data are available on the efficacy of visual or tactile devices designed to enhance patient understanding and control of portion sizes. A portion control plate is a commercially-available product that can provide visual cues of portion size and potentially contribute to weight loss by enhancing portion size control among obese patients. This tool holds promise as a useful adjunct to dietary counseling. Our objective was to evaluate a portion control intervention including dietary counseling and a portion control plate to facilitate weight loss among obese patients in a primary care practice. FINDINGS: We randomized 65 obese patients [body mass index (BMI) ≥ 30 and < 40] to an intervention including counseling by a dietitian incorporating a portion control plate or to usual care. Following initial consultation, patients in the intervention arm were contacted at 1, 3, and 5 months by the dietician for brief follow-up counseling. Usual care subjects received instructional handouts on diet and exercise. Forty-two (65%) subjects returned to have weight assessed at 6 months. Subjects in the portion control intervention had a greater percentage change (± SD) in weight from baseline at 3 months (-2.4% ± 3.7% vs. -0.5% ± 2.2%; p = 0.041) and a non significant trend in weight change from baseline at 6 months (-2.1% ± 3.8% vs. -0.7% ± 3.7%; p = 0.232) compared with usual care. Nearly one-half of patients assigned to the portion control intervention who completed the study reported the overall intervention was helpful and the majority would recommend it to others. CONCLUSIONS: Our findings suggest that a portion control intervention incorporating dietary counseling and a portion control plate may be effective for enhancing weight loss among obese subjects. A portion control intervention deserves further evaluation as a weight control strategy in the primary care setting. TRIAL REGISTRATION: Current controlled trials NCT01451554.