Clinical Reasoning: Perspectives of Expert Clinicians on Reasoning Through Complex Clinical Cases.

Introduction Clinical reasoning is a core skill for physicians; most doctors do not attain the level of expertise associated with that of an expert clinician (EC). The purpose of this study is to identify the clinical reasoning strategies ECs prioritize when reasoning through complex cases. Methods We interviewed 14 ECs and performed a thematic analysis to identify strategies ECs prioritize when reasoning through complex clinical cases. The authors chose ECs based on the recognition of clinical and teaching expertise by trainees and other faculty members (ECs within our institution) and institutional recognition of high achievement in medicine and medical education (ECs outside our institution). We used a semi-structured guide to interview each EC, then reviewed and coded the interview transcriptions. We developed themes based on agreements between all transcript reviewers.  Results We interviewed 11 male and three female ECs, one from outside the study institution. Two (14%) ECs were primary care physicians, and the remaining were sub-specialists. The authors organized strategies for clinical reasoning through complex cases around four themes, which were as follows: (1) connecting clinical reasoning to patient context; (2) embracing uncertainty, then reducing it; (3) returning to the patient's bedside; and (4) remaining humble to limit diagnostic errors. Conclusion Clinical reasoning is a core clinical skill of physicians, and this article describes clinical reasoning strategies prioritized by ECs for complex clinical cases. Recognition and integration of these strategies into medical training and clinical educator practice may facilitate the evolution of clinical reasoning skills and reduce diagnostic errors.

Strategies to Improve Teaching Point-of-Care Ultrasound at the Bedside.

Point-of care-ultrasound (POCUS) is becoming a core clinical skill in many medical specialties. Teaching POCUS at the bedside allows for observation of learners during actual patient encounters, provides a medium for role modeling skills and behaviors, and incorporates all core POCUS competencies. Nonetheless, bedside teaching can be time consuming and intimidating for learners and teachers, and the full benefits of teaching at the bedside can be difficult to attain. We provide strategies for improving bedside POCUS teaching based on our collective experience as medical educators and POCUS instructors at both the undergraduate and graduate levels in medical education.

Anthropomorphic Character Animations Versus Digital Chalk Talks in a Resident Diabetes Pharmacotherapy Curriculum: a Randomized Controlled Trial.

BACKGROUND: Animation in medical education has boomed over the past two decades, and demand for distance learning technologies will likely continue in the context of the COVID-19 pandemic. However, experimental data guiding best practices for animation in medical education are scarce. OBJECTIVE: To compare the efficacy of two animated video styles in a diabetes pharmacotherapy curriculum for internal medicine residents. DESIGN: Learners were randomized to receive one of two versions of the same multimodal didactic curriculum. They received identical lectures, group activities, and quizzes, but were randomized to either digital chalk talk (DCT) videos or Sugar-Coated Science (SCS). SCS is an animated series using anthropomorphic characters, stories, and mnemonics to communicate knowledge. PARTICIPANTS: Ninety-two internal medicine residents at a single academic medical center received the curriculum within ambulatory medicine didactics. MAIN MEASURES: Knowledge was measured at multiple time points, as was residents' self-reported comfort using each medication class covered. Surveys assessed video acceptability and telepresence. Key themes were identified from open-ended feedback. KEY RESULTS: Baseline knowledge was low, consistent with prior needs assessments. On immediate posttest, mean scores were higher with SCS than DCT (74.8% versus 68.4%), but the difference was not statistically significant, p = 0.10. Subgroup analyses revealed increased knowledge in the SCS group for specific medication classes. Delayed posttest showed significant knowledge gains averaging 17.6% across all participants (p < 0.05); these gains were similar between animation types. SCS achieved significantly higher telepresence, entertainment, and acceptability scores than DCT. Qualitative data suggested that residents prioritize well-designed, multimodal curricula over specific animation characteristics. CONCLUSION: SCS and DCTs both led to learning within a multimodal curriculum, but SCS significantly enhanced learner experience. Animation techniques exemplified by both SCS and DCTs have roles in the medical educator toolkit. Selection between them should incorporate context, learner factors, and production resources.

Becoming Clinician-Animators: a Toolkit and Pilot Study for Novel Animated Content Development in a Medical Education Curriculum.

Animation is increasingly incorporated into multimedia teaching tools in medical education. Despite enthusiasm about animation among learners and educators, evidence is limited and conflicting regarding the effectiveness of animation in medical education. In this how-to guide and pilot study, a team of clinician-educators have cataloged their efforts to learn the art of animation and understand how to most effectively integrate animation into a flipped classroom curriculum. In this pilot, internal medicine residents responded that an animated video series using anthropomorphic characters and metaphorical dialogue and narrative was an accessible, acceptable, and effective method of teaching the antihyperglycemic medications for type 2 diabetes mellitus. This study paves a path for further exploration of the intersection between multimedia, entertainment, and cognitive theory in graduate medical education.

The Changing Face of HIV Care: Expanding HIV Training in an Internal Medicine Residency Program.

PROBLEM: People with HIV/AIDS are living longer and are at an increased risk of comorbidities. A qualified physician workforce is needed to care for this growing population. APPROACH: In 2012, a novel three-year HIV training track (HIV TT) was implemented as part of the Yale Primary Care Residency Program. To prepare for the implementation of this program, a needs assessment was performed, a web-based curriculum and 12 HIV-specific entrustable professional activities (EPAs) were created, and adequate clinical training opportunities in HIV and primary care were established. Program evaluation included process, learner, and outcome evaluations from 2012 to 2017. OUTCOMES: Since its inception, the HIV TT has enrolled a total of 11 residents (6-7 at a time), with 5 graduating to date. Residents delivered high-quality HIV and primary care for a diverse panel of patients; improved their knowledge and performance in HIV care, including according to the HIV-specific EPAs; and were highly satisfied with the program. All faculty remained with the program, and patients indicated satisfaction. NEXT STEPS: Next steps include enhanced coordination of residents' schedules, improved EPA documentation, evaluation of residents' HIV and non-HIV competence beyond residency, and monitoring graduates' career trajectories. Expanding HIV training within internal medicine residency programs is feasible and effective and has the potential to alleviate the shortage of physicians trained to provide HIV care and primary care in a single setting.

Objective Structured Clinical Examination-Based Teaching of the Musculoskeletal Examination.

OBJECTIVES: Musculoskeletal complaints are the most common presenting illnesses in primary care settings, yet physicians often are underprepared to manage such complaints. We sought to create and evaluate an objective structured clinical examination (OSCE)-based musculoskeletal workshop designed to simultaneously educate medical students and internal medicine residents, enlisting volunteer medical students as standardized patients (SPs). METHODS: The setting for the study was the Yale Primary Care Residency Program. A comprehensive OSCE-based musculoskeletal workshop series was created, consisting of standalone workshops with evidence-based interactive lectures followed by OSCE stations. At each station, residents are evaluated on physical examination skills, differential diagnosis, and therapeutic plan. We assessed the impact of exposure to the neck/back pain workshop using written knowledge and clinical skills tests (maximum score 32) among both residents and medical students 6 months after exposure. RESULTS: A convenience sample of 13 residents exposed to the neck/back pain workshop was compared with 17 unexposed residents. Six months after exposure to the workshop, exposed residents, compared with unexposed residents, performed significantly better on a written knowledge test (score 8.6 vs 6.8, P = 0.005) and the clinical skills test (score 20.9 vs 17.1, P = 0.007). Similarly, medical student SPs performed significantly better on the clinical skills test (17.0 vs 12.0, P = 0.02), compared with the control students. CONCLUSIONS: Our novel OSCE-based musculoskeletal workshop, which enlists medical students to serve as SPs, engendered sustainable improvements in knowledge and clinical skills among both residents and participating students, thereby offering an innovative approach to simultaneously meeting both undergraduate and graduate medical education needs.

Community-acquired MRSA pyomyositis: case report and review of the literature.

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is responsible for a broad range of infections. We report the case of a 46-year-old gentleman with a history of untreated, uncomplicated Hepatitis C who presented with a 2-month history of back pain and was found to have abscesses in his psoas and right paraspinal muscles with subsequent lumbar spine osteomyelitis. Despite drainage and appropriate antibiotic management the patient's clinical condition deteriorated and he developed new upper extremity weakness and sensory deficits on physical exam. Repeat imaging showed new, severe compression of the spinal cord and cauda equina from C1 to the sacrum by a spinal epidural abscess. After surgical intervention and continued medical therapy, the patient recovered completely. This case illustrates a case of CA-MRSA pyomyositis that progressed to lumbar osteomyelitis and a spinal epidural abscess extending the entire length of the spinal canal.

Intravascular pressure and diameter profile of the utero-ovarian resistance artery network: estrous cycle-dependent modulation of resistance artery tone.

Blood flow to the ovary varies dramatically in both magnitude and distribution throughout the estrous cycle to meet the hormonal and metabolic demands of the ovarian parenchyma as it cyclically develops and regresses. Several vascular components appear to be critical to vascular regulation of the ovary. As a first step in resolving the role of the resistance arteries and their paired veins in regulating ovarian blood flow and transvascular exchange, we characterized the architecture and intravascular pressure profile of the utero-ovarian resistance artery network in an in vivo preparation of the ovary of the anesthetized Golden hamster. We also investigated estrous cycle-dependent changes in resistance artery tone. The right ovary and the cranial aspect of the uterus in 26 female hamsters were exposed for microcirculatory observations. Estrous-cycle phase was determined in each animal before experimentation. The utero-ovarian vascular architecture was determined and resistance artery diameters were measured in each animal by video microscopy. Servo-null intravascular pressure measurements were made throughout the uteroovarian arterial network in 11 of the animals. Architectural data showed a complex anastomotic network jointly supplying the uterus and ovary. Resistance arteries showed a high degree of coiling and close apposition to veins, maximizing countercurrent-exchange capabilities. Arterial pressure dropped below 60% of systemic arterial pressure before the arteries entered the ovary. Both the ovarian artery and the uterine artery, which jointly feed the ovary, showed cycle day-dependent changes in diameter. Arterial diameters were smallest on the day following ovulation, during the brief luteal phase of the hamster. The data show that resistance arteries comprise a critical part of a complex network designed for intimate local communication and control and suggest that these arteries may play an important role in regulating ovarian blood flow in an estrous cycle-specific manner.