Assessment of management reasoning: Design considerations drawn from analysis of simulated outpatient encounters.

PURPOSE: Management reasoning is a distinct subset of clinical reasoning. We sought to explore features to be considered when designing assessments of management reasoning. METHODS: This is a hybrid empirical research study, narrative review, and expert perspective. In 2021, we reviewed and discussed 10 videos of simulated (staged) physician-patient encounters, actively seeking actions that offered insights into assessment of management reasoning. We analyzed our own observations in conjunction with literature on clinical reasoning assessment, using a constant comparative qualitative approach. RESULTS: Distinguishing features of management reasoning that will influence its assessment include management scripts, shared decision-making, process knowledge, illness-specific knowledge, and tailoring of the encounter and management plan. Performance domains that merit special consideration include communication, integration of patient preferences, adherence to the management script, and prognostication. Additional facets of encounter variation include the clinical problem, clinical and nonclinical patient characteristics (including preferences, values, and resources), team/system characteristics, and encounter features. We cataloged several relevant assessment approaches including written/computer-based, simulation-based, and workplace-based modalities, and a variety of novel response formats. CONCLUSIONS: Assessment of management reasoning could be improved with attention to the performance domains, facets of variation, and variety of approaches herein identified.

ISBARR Huddle: First-Year Medical Students Managing Critical Hypoglycemia as an Interprofessional Team.

Introduction: Recognizing a patient requiring urgent or emergent care and initiating evaluation and management must include elements that support teams working and thinking together. Although team communication strategies exist, a standardized approach for communicating about patients with urgent or emergent conditions is lacking. This simulation was designed to provide first-semester medical students with the opportunity to deliberately practice the foundational teamwork skills required to think as a team while caring for a patient with critical hypoglycemia. Methods: Students were introduced to a team huddle that was structured using ISBARR (identify, situation, background, assessment, recommend, recap) to assist in synthesizing gathered information and arriving at a diagnosis and associated care plan. Students practiced in small groups with faculty coaches and then applied the skills learned to two cases of a patient with critical hypoglycemia followed by debriefing. Results: Two hundred eight first-semester medical students participated in the simulation course across three campuses. We surveyed a single campus subset of 172 students. One hundred thirty-three students completed a postevent survey. The majority felt that the difficulty of the simulation was appropriate for their educational level (94%) and that the training would be applicable to real-life clinical events (76%) and would improve the quality and safety of care (100%). Survey comments highlighted teamwork and the use of the ISBARR huddle communication tool. Discussion: The course provided first-semester medical students with standardized practice of a team-based approach using huddle communication to advance patient care.

Standardized Patients to Assess Resident Interpersonal Communication Skills and Professional Values Milestones.

It has been a challenge to assess communication and professional values Milestones in emergency medicine (EM) residents using standardized methods, as mandated by the Accreditation Council for Graduate Medical Education (ACGME). This paper outlines an innovative method of assessing these Milestones using an established instructional method. EM faculty mapped the communication and professional values Milestones to an existing communication and interpersonal skills scale. We identified six communication-focused scenarios: death notification; informed consent; medical non-compliance; medical error; treatment refusal; and advanced directives. In a pilot, 18 EM residents completed these six standardized patient (SP) encounters. Our experience suggests SP encounters can support standardized direct observation of residents' achievement of ACGME Milestones. Further effort can be made to create a tailored, behaviorally-anchored tool that uses the Milestones as the conceptual framework.