Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research.

From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.

Middle school meets MedEd: Five K-12 teaching strategies medical educators should know.

While the COVID-19 pandemic has challenged the way medical educators develop and deliver content, it has also presented an opportunity for innovation. As students, trainees, and faculty design new curricula and employ new learning modalities, primary and secondary school offer a wealth of teaching strategies and ideas for medical education. In this Personal View, the authors share their experience as former middle school teachers and current medical students to offer five valuable teaching strategies - backwards planning, the 5E model, setting norms, scaffoldings, and checks for understanding (CFUs) - for medical educators to incorporate into their practice.

Screens in the back: Medical student perspective on curriculum engagement.

Medical students in the United States are engaging less with formal classroom curricula. This shift in decreased attendance and participation is largely driven by an incentive structure in medical education focused on standardized test scores, research and letters of recommendation. In this essay, the authors describe the student experience of a preclinical lecture, struggling to balance learning about a patient with Alcohol Use Disorder with the demands of extracurricular expectations.

Making Sense of Trainee Performance: Entrustment Decision-Making in Internal Medicine Program Directors.

Background: Competency-based assessment is an important but challenging aspect of residency education but determines trainees' progression towards the ultimate goal of graduation. Entrustment decision making has been proposed as a supplementary metric to assess trainee competence. This study explores the process by which Program Directors (PDs) make entrustment decisions in Internal Medicine (IM) training programs. Study Design: Purposive sampling was used to recruit PDs from ACGME-accredited IM training programs to participate in a semi-structured interview. We analyzed interviews using an iterative, grounded theory-based approach to allow identification of themes that define the process of trainee entrustment. Results: Sixteen PDs were interviewed. Qualitative analysis showed that PDs use a dynamic process to understand trainee entrustability and progression towards competence, including construction of assessment networks, comparing performance to expected trajectory of trainee competence development, and bidirectional filtering and weighing of assessment data. Conclusions: PDs serve as a central processor by which assessment data on trainees is filtered, weighted, and compared an expected trajectory, all to gain understanding of trainee performance. Assessment networks are crucial to understanding trainee competence. While expected trajectory is an important tool to determine how trainees are progressing, its continued use may inject bias into the assessment process and slow transition to true competency-based assessment.

Five Medical Education Podcasts You Need to Know.

Podcasts have become increasingly popular tools for medical education in recent years. Only requiring a computer or smart phone, podcasts are readily accessible to healthcare professionals, helping to disseminate medical information quickly and creating a wide community of listeners. With numerous medical podcasts available and limited spare time, it can be challenging for a healthcare professional to identify the most high-yield podcast. This perspectives piece describes the role of podcasts in medical education before sharing five in-depth recommendations from Yale School of Nursing and Yale School of Medicine students and faculty. These five podcasts are: The Curbsiders Internal Medicine Podcast, Flip the Script, The Clinical Problem Solvers, 2 Docs Talk, and Key Literature in Medical Education (KeyLIME) Podcast. Each podcast summary includes its average length, the episode frequency, the intended audience, a brief description, a representative episode, and quotes from interviews with the podcast hosts.

The future of teaching management reasoning: important questions and potential solutions.

Management reasoning is distinct from but inextricably linked to diagnostic reasoning in the iterative process that is clinical reasoning. Complex and situated, management reasoning skills are distinct from diagnostic reasoning skills and must be developed in order to promote cogent clinical decisions. While there is growing interest in teaching management reasoning, key educational questions remain regarding when it should be taught, how it can best be taught in the clinical setting, and how it can be taught in a way that helps mitigate implicit bias. Here, we describe several useful tools to structure teaching of management reasoning across learner levels and educational settings. The management script provides a scaffold for organizing knowledge around management and can serve as a springboard for discussion of uncertainty, thresholds, high-value care, and shared decision-making. The management pause reserves space for management discussions and exploration of a learner's reasoning. Finally, the equity reflection invites learners to examine management decisions from a health equity perspective, promoting the practice of metacognition around implicit bias. These tools are easily deployable, and - when used regularly - foster a learning environment primed for the successful teaching of management reasoning.

Inpatient teaching with a clinical review game.

BACKGROUND: Shortened preclinical curricula, social distancing policies and the fast-paced nature of inpatient medicine make clinical education challenging. Crowdsourced learning and a review game derived from real-time patient cases can offer an engaging solution for inpatient teaching. APPROACH: We implemented a clinical review game with 67 participants (10 physician instructors, 40 residents and 17 medical students) rotating through the adult inpatient medicine service at an academic medical centre from July 2018 through July 2020. During 2-week rotations, participants identified shareable teaching points about their patients on rounds. Teaching points were compiled by an instructor into a 30-minute end-of-rotation review game formatted from a free gameshow-based PowerPoint template. After the review game was completed, learners were then asked to complete end-of-rotation evaluations. EVALUATION: Learners were surveyed on their educational experience, and teaching point submissions were studied. After eight rotations, 39 participants (39/67 = 58.2% response rate) submitted a total of 268 teaching points, and nearly half of which were from learners (n = 131 [48.9%]). In the review game, 35 residents and 17 medical students participated and correctly answered 80% of questions. Learner evaluations highlighted the activity strengths including self-directed learning, peer teaching from primary literature and a warm, collaborative educational environment. IMPLICATIONS: Our crowdsourced clinical review game approach helped to highlight clinically relevant content for teaching rounds, build a collaborative culture across trainee levels and encourage self-study for trainees to stay informed with current evidence-based practice, even during pandemic restrictions.

The Management Script: A Practical Tool for Teaching Management Reasoning.

Management reasoning, a component of clinical reasoning, has become an important area for medical education research given its inherent complexity, role in medical decision making, and association with high-value care. Teaching management reasoning requires characterizing its core concepts and identifying strategies to teach them. In this Perspective, the authors propose the term "management script" to describe the mental schema that clinicians develop and use in medical decision making. Management scripts are high-level, precompiled, conceptual knowledge structures of the courses of action that a clinician may undertake to address a patient's health care problem(s). Like illness scripts, management scripts have foundational elements that are shared by most clinicians but are ultimately idiosyncratic based on each clinician's unique history of learning and experience. Applying management scripts includes 2 steps-(1) management script activation and (2) management option selection-which can occur reflexively (unconsciously) or deliberately (consciously), similar to, respectively, the System 1 thinking and System 2 thinking of dual process theory. Management scripts can be taught for different conditions by using management script templates, educational scaffolds that provide possible courses of action to address a health care problem at any stage. Just as learners use system-based or organ-based frameworks to generate a differential diagnosis, students can use a generic management script template early in training to develop management scripts for specific problems. Future research directions include exploring the role of management scripts in medical education and quality improvement practices.

Controversies in diagnosis: contemporary debates in the diagnostic safety literature.

Since the 2015 publication of the National Academy of Medicine's (NAM) Improving Diagnosis in Health Care (Improving Diagnosis in Health Care. In: Balogh EP, Miller BT, Ball JR, editors. Improving Diagnosis in Health Care. Washington (DC): National Academies Press, 2015.), literature in diagnostic safety has grown rapidly. This update was presented at the annual international meeting of the Society to Improve Diagnosis in Medicine (SIDM). We focused our literature search on articles published between 2016 and 2018 using keywords in Pubmed and the Agency for Healthcare Research and Quality (AHRQ)'s Patient Safety Network's running bibliography of diagnostic error literature (Diagnostic Errors Patient Safety Network: Agency for Healthcare Research and Quality; Available from: https://psnet.ahrq.gov/search?topic=Diagnostic-Errors&f_topicIDs=407). Three key topics emerged from our review of recent abstracts in diagnostic safety. First, definitions of diagnostic error and related concepts are evolving since the NAM's report. Second, medical educators are grappling with new approaches to teaching clinical reasoning and diagnosis. Finally, the potential of artificial intelligence (AI) to advance diagnostic excellence is coming to fruition. Here we present contemporary debates around these three topics in a pro/con format.

All Other Things Being Equal: Exploring Racial and Gender Disparities in Medical School Honor Society Induction.

PURPOSE: A large body of literature has demonstrated racial and gender disparities in the physician workforce, but limited data are available regarding the potential origins of these disparities. To that end, the authors evaluated the effects of race and gender on Alpha Omega Alpha Honor Medical Society (AOA) and Gold Humanism Honor Society (GHHS) induction. METHOD: In this retrospective cohort study, the authors examined data from 11,781 Electronic Residency Application Service applications from 133 U.S. MD-granting medical schools to 12 residency programs in the 2014-2015 application cycle and to all 15 residency programs in the 2015-2016 cycle at Yale-New Haven Hospital. They estimated the odds of induction into AOA and GHHS using logistic regression models, adjusting for Step 1 score, research publications, citizenship status, training interruptions, and year of application. They used gender- and race-matched samples to account for differences in clerkship grades and to test for bias. RESULTS: Women were more likely than men to be inducted into GHHS (odds ratio 1.84, P < .001) but did not differ in their likelihood of being inducted into AOA. Black medical students were less likely to be inducted into AOA (odds ratio 0.37, P < .05) but not into GHHS. CONCLUSIONS: These findings demonstrate significant differences between groups in AOA and GHHS induction. Given the importance of honor society induction in residency applications and beyond, these differences must be explored further.