Teaching Students How to Think: A Longitudinal Qualitative Study of Preclerkship Clinical Reasoning Instruction.

INTRODUCTION: An objective of undergraduate medical education is to teach students how to think like physicians through a process called clinical reasoning. Currently, clerkship directors often feel that students enter their clinical years with a marginal comprehension of clinical reasoning concepts; instruction in this area could be improved. Although there have been previous educational studies assessing curricular interventions to improve the instruction of clinical reasoning, it is not yet known what happens at an individual level between an instructor and a small group of students in the teaching of clinical reasoning. This research will identify how clinical reasoning is being taught in a longitudinal clinical reasoning course. METHODS: The Introduction to Clinical Reasoning course is a 15-month-long case-based course held in the preclinical curriculum of the USU. Individual sessions involve small-group learning with approximately seven students per group. Throughout the academic year of 2018-2019, 10 of these sessions were videotaped and transcribed. All participants provided informed consent. A thematic analysis was performed using a constant comparative approach. Transcripts were analyzed until thematic sufficiency was reached. RESULTS: Over 300 pages of text were analyzed; new themes ceased to be identified after the eighth session. Topics included obstetrics, general pediatric issues, jaundice, and chest pain; these sessions were taught either by attendings, fellows, or fourth-year medical students with attending supervision. The thematic analysis revealed themes associated with clinical reasoning processes, themes associated with knowledge organization, and a theme associated with clinical reasoning in the military. The clinical reasoning process themes included problem list construction and refinement, differential diagnosis, naming and defending a leading diagnosis, and clinical reasoning heuristics. The knowledge organization themes included illness script development and refinement and semantic competence. The final theme was military relevant care. CONCLUSIONS: In individual teaching sessions, preceptors emphasized problem lists, differential diagnoses, and leading diagnoses in a course designed to strengthen diagnostic reasoning in preclerkship medical students. The use of illness scripts was more often implicitly used rather than explicitly stated, and students used these sessions to use and apply new vocabularies related to a clinical presentation. Instruction in clinical reasoning could be improved by encouraging faculty to provide further context to their thinking, by encouraging the comparing and contrasting of illness scripts, and by using a shared vocabulary for clinical reasoning. Limitations of this study include that it was done in the context of a clinical reasoning course and that it was done at a military medical school, which may limit generalizability. Future studies could determine if faculty development could improve the frequency of references to the clinical reasoning processes that could improve student readiness for clerkship.

Divergence and Dissonance in Residents' Reported and Actual Feedback to Faculty in a Military Context.

INTRODUCTION: Trainees (e.g., residents) are an obvious and common source of feedback for faculty; however, gaps exist in our understanding of their experiences and practices of providing such feedback. To gain a deeper understanding, this study examined residents' beliefs about what feedback is important to provide, the kinds of feedback they report giving, and the feedback they actually gave. MATERIALS AND METHODS: Descriptive statistics were used to analyze residents' perceptions and feedback behaviors (n = 42/96). Thematic analysis was used to analyze end-of-rotation faculty assessments from 2018 to 2019 (n = 559) to explore the actual written feedback residents provided to the faculty. RESULTS: The findings suggest that residents experience workload constraints (e.g., too many feedback requests), feel that their feedback is not valuable or relevant, and place conditions on when and what feedback is given (e.g., faculty agreeableness, prefer giving positively oriented feedback, and uncomfortable giving negative feedback). When comparing what feedback residents rated as important with the kinds of feedback they reported giving and actually gave, the findings also suggest that there were consistencies (e.g., clinical instruction and professionalism) and inconsistencies (e.g., evidence-based practice and medical knowledge) that may limit constructive feedback for faculty. CONCLUSIONS: Taken together, the findings suggest that trainee assessments of faculty may be insufficient as a primary source of feedback to support the improvement of faculty performance. Potential solutions are discussed.

Treatment of Patients Hospitalized with COVID-19 in a US Military Role 3 Facility in Afghanistan: A Case Series.

BACKGROUND: COVID-19, caused by SARS CoV-2, is an acute respiratory viral illness. We present the experience of treating patients hospitalized with COVID-19 in a Role 3 hospital in an active warzone. METHODS: This is a retrospective care series of patients treated for COVID-19 at Craig Joint Theater Hospital, Bagram, Afghanistan from May to August 2020. Data extracted included demographics, admission and disposition information, past medical history, comorbidities, Transportation Command (TRANSCOM) severity classification (i.e. Category A, Category B), and treatments received. RESULTS: This series included 15 Category A and 55 Category B patients. Most patients were non-US contractors with one chronic condition. Most patients received medical treatments in accordance with Department of Defense Practice Management Guidelines. For Category A patients, mechanical ventilation use declined from a mean average of 10.67 days to 2.83 days following the introduction of high-flow nasal cannula. Average hospital length of stay was 6 days (range 2-23). One death occurred in a patient greater than 60 years old with three known prior medical conditions. Most patients were discharged to a non-medical isolation facility. Aeromedically evacuated patients were mostly US military and US contractors. CONCLUSION: We faced several challenges including retrofitting a Role 3 facility designed for trauma care for management of a highly contagious respiratory viral illness. Logistics constraints impacted timely delivery of medical therapies and equipment and decreased efficiency of aeromedical evacuation. Despite these challenges and the simultaneous trauma mission, most patients received medical care in accordance with treatment guidelines with a low mortality rate.

Statin-Induced Immune-Mediated Necrotizing Myopathy: An Increasingly Recognized Inflammatory Myopathy.

Statin-induced immune-mediated necrotizing myopathy, also known as anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) myopathy, is an inflammatory myopathy that is triggered by statin exposure and persists after statin discontinuation. It is a rare side effect of statins, distinct from the more commonly recognized statin-induced myalgia, that is challenging to diagnose and treat. We describe a case of anti-HMGCR myopathy in a 59-year-old male with a prior history of statin intolerance presenting with markedly elevated creatinine kinase, myoglobinuria, and one month of progressive proximal muscle weakness after restarting atorvastatin 10 months prior to admission. High-dose glucocorticoids led to rapid clinical improvement, although the patient relapsed upon tapering. Remission was attained at three months after combination therapy with azathioprine, intravenous immunoglobulin, and a prolonged prednisone taper.

Reducing the Inappropriate Use of Proton Pump Inhibitors in an Internal Medicine Residency Clinic.

Introduction Proton pump inhibitors (PPI) are commonly prescribed in the primary care setting. While generally considered to be safe, there is growing evidence suggesting that PPI misuse is associated with a variety of significant adverse outcomes and unnecessary cost. The goal of this quality improvement project was to identify patients with non-guideline recommended PPI prescriptions in our internal medicine residency clinics and implement a process to de-prescribe or reduce the dose of PPIs across this patient population. Methods PPI prescription rates, dosage, and indication were extracted from the medical records of all 854 patients empaneled to the internal medicine residency clinics at a multicenter closed referral military hospital system. Appropriate PPI indication was consensus based upon published guidelines, and patients without an appropriate indication were targeted for intervention. These patients were directly contacted by their primary care physicians, via phone or during a clinic visit, to discuss the risks and benefits of ongoing PPI use as well as alternative therapies or tapering regimens at the physician's discretion. For moderate to high dose PPI, the dose was decreased by 50% every week until the lowest tolerated dose was achieved or until discontinuation. For low dose PPI, discontinuation was recommended as the initial intervention. Six months following the intervention, the empanelment was reevaluated for ongoing PPI usage, tapered dosage, or discontinuation. Results Of a total of 854 patient records reviewed at the initiation of the project, 322 patients were noted to be prescribed PPIs. Of this subset, 66% (217/322) did not meet a guideline recommended indication for their use. At the completion of the six-month intervention period, 44% (96/217) of patients were successfully weaned to a reduced dose or were no longer using a PPI. Conclusions PPIs are widely used and generally considered to be a well-tolerated therapy for acid-secretion disorders. PPI overprescription and the associated adverse effects and economic burden are increasingly recognized. We show that a simple, focused, resident-driven quality improvement intervention can be effective in de-prescribing efforts to reduce inappropriate PPI use in the outpatient primary care setting.

Tranexamic Acid Use in a Patient with a Life-threatening Bleed Exacerbated by Coagulopathy Due to an Aortic Aneurysm with an Endoleak: A Case Report.

Tranexamic acid (TXA) is an anti-fibrinolytic agent that inhibits plasminogen activation by binding to its lysine receptor sites and preventing its conversion to plasmin. It stabilizes clots to reduce bleeding and has been used in the setting of trauma, heavy menstrual bleeding, and hematologic malignancies. To our knowledge, there is no mention in the literature of medical management with TXA to treat a life-threatening hemorrhage in the setting of non-operative, endoleakage-induced, chronic disseminated intravascular coagulation (DIC). This case report summarizes the successful use of TXA in a patient with DIC secondary to multiple aortic aneurysms and endoleakage in an effort to stop the expansion of a life-threatening gluteal hematoma not amenable to surgical or vascular intervention.

Aggravation and deliberation over lung herniation.

A Caucasian woman aged 58 years with history of asthma and surgically repaired congenital diaphragmatic hernia presented to the emergency department (ED) with persistent cough, pleuritic chest pain, shortness of breath, in spite of recent treatment for influenza A virus. On physical examination, a large bulge was protruding from her left posterior thorax. She was found to have a large abnormal radiographic lucency on lateral chest X-ray posterior to the thoracic cavity, confirmed with chest CT to represent a large lung herniation in between the left seventh and eighth ribs. The patient was evaluated by a thoracic surgeon and offered surgical repair but ultimately decided on conservative management which to date has been ineffective.

A mixed-methods exploration of cognitive dispositions to respond and clinical reasoning errors with multiple choice questions.

BACKGROUND: Cognitive dispositions to respond (i.e., cognitive biases and heuristics) are well-established clinical reasoning phenomena. While thought by many to be error-prone, some scholars contest that these cognitive dispositions to respond are pragmatic solutions for reasoning through clinical complexity that are associated with errors largely due to hindsight bias and flawed experimental design. The purpose of this study was to prospectively identify cognitive dispositions to respond occurring during clinical reasoning to determine whether they are actually associated with increased odds of an incorrect answer (i.e., error). METHODS: Using the cognitive disposition to respond framework, this mixed-methods study applied a constant comparative qualitative thematic analysis to transcripts of think alouds performed during completion of clinical-vignette multiple-choice questions. The number and type of cognitive dispositions to respond associated with both correct and incorrect answers were identified. Participants included medical students, residents, and attending physicians recruited using maximum variation strategies. Data were analyzed using generalized estimating equations binary logistic model for repeated, within-subjects measures. RESULTS: Among 14 participants, there were 3 cognitive disposition to respond categories - Cognitive Bias, Flaws in Conceptual Understanding, and Other Vulnerabilities - with 13 themes identified from the think aloud transcripts. The odds of error increased to a statistically significant degree with a greater per-item number of distinct Cognitive Bias themes (OR = 1.729, 95% CI [1.226, 2.437], p = 0.002) and Other Vulnerabilities themes (OR = 2.014, 95% CI [1.280, 2.941], p < 0.001), but not with Flaws in Conceptual Understanding themes (OR = 1.617, 95% CI [0.961, 2.720], p = 0.070). CONCLUSION: This study supports the theoretical understanding of cognitive dispositions to respond as phenomena associated with errors in a new prospective manner. With further research, these findings may inform teaching, learning, and assessment of clinical reasoning toward a reduction in patient harm due to clinical reasoning errors.

Exploring examinee behaviours as validity evidence for multiple-choice question examinations.

CONTEXT: Clinical-vignette multiple choice question (MCQ) examinations are used widely in medical education. Standardised MCQ examinations are used by licensure and certification bodies to award credentials that are meant to assure stakeholders as to the quality of physicians. Such uses are based on the interpretation of MCQ examination performance as giving meaningful information about the quality of clinical reasoning. There are several assumptions foundational to these interpretations and uses of standardised MCQ examinations. This study explores the implicit assumption that cognitive processes elicited by clinical-vignette MCQ items are like the processes thought to occur with 'real-world' clinical reasoning as theorised by dual-process theory. METHODS: Fourteen participants (three medical students, five residents and six staff physicians) completed three sets of five timed MCQ items (total 15) from the Medical Knowledge Self-Assessment Program (MKSAP). Upon answering a set of MCQs, each participant completed a retrospective think aloud (TA) protocol. Using constant comparative analysis (CCA) methods sensitised by dual-process theory, we performed a qualitative thematic analysis. RESULTS: Examinee behaviours fell into three categories: clinical reasoning behaviours, test-taking behaviours and reactions to the MCQ. Consistent with dual-process theory, statements about clinical reasoning behaviours were divided into two sub-categories: analytical reasoning and non-analytical reasoning. Each of these categories included several themes. CONCLUSIONS: Our study provides some validity evidence that test-takers' descriptions of their cognitive processes during completion of high-quality clinical-vignette MCQs align with processes expected in real-world clinical reasoning. This supports one of the assumptions important for interpretations of MCQ examination scores as meaningful measures of clinical reasoning. Our observations also suggest that MCQs elicit other cognitive processes, including certain test-taking behaviours, that seem 'inauthentic' to real-world clinical reasoning. Further research is needed to explore if similar themes arise in other contexts (e.g. simulated patient encounters) and how observed behaviours relate to performance on MCQ-based assessments.

Accuracy of traditional age, gender and symptom based pre-test estimation of angiographically significant coronary artery disease in patients referred for coronary computed tomographic angiography.

Determining the pretest probability of angiographically significant (≥50% stenosis) coronary artery disease (CAD) in symptomatic patients relies on the Diamond and Forrester (DF) classification, which was derived from a cohort referred for invasive coronary angiography. The accuracy of this approach in patients referred for noninvasive coronary angiography is not fully known. Consecutive patients without known CAD referred for coronary computed tomographic angiography (CCTA) were evaluated. Chest pain was prospectively categorized as nonanginal, atypical angina, typical angina, or asymptomatic. The pretest likelihood of angiographically significant CAD was estimated using DF classification and compared with observed rates of angiographically significant CAD on CCTA. Among 1,027 patients (41% women; mean age 50 ± 12 years), 38 (4%) had nonanginal symptoms, 643 (63%) had atypical angina, 72 (7%) had typical angina, and 274 (26%) were asymptomatic. The prevalence of angiographically significant CAD in patients with nonanginal chest pain, atypical angina, typical angina, and no symptoms was 1 (3%), 55 (9%), 14 (19%), and 25 (9%), respectively (p <0.001). DF classification significantly overestimated angiographically significant CAD prevalence across all symptom classifications, genders, and ages despite adjustment for risk factors (p <0.001 for all comparisons). DF classification had an area under the receiver-operating characteristic curve of 0.72 (95% confidence interval 0.66 to 0.78), which was not significantly different from age alone (0.69) or age, symptoms, and risk factors (0.68). In conclusion, in a low- to intermediate-risk cohort referred for CCTA, DF classification significantly overestimated angiographically significant CAD prevalence across all age, gender, and symptom strata. The DF classification may overestimate the pretest probability of angiographically significant CAD in contemporary patients referred for CCTA.

Changes in preventive medical therapies and CV risk factors after CT angiography.

OBJECTIVES: The aim of the study was to determine the association of coronary computed tomographic angiography (CTA)-identified coronary artery disease (CAD) with post-test aspirin, statin, and antihypertensive medication use and changes in cholesterol and blood pressure (BP). BACKGROUND: The relationship of CTA findings to subsequent changes in preventive cardiovascular medication prescribing patterns and risk factors is largely unknown. METHODS: We studied 1,125 consecutive patients without known CAD referred for coronary CTA. CAD was defined as none, nonobstructive (<50%), or obstructive (≥50%). Prescriptions were queried in the 6 months pre- and post-CTA for comparison of aspirin, statin, and BP treatment. Medication intensification was defined as initiation, dose increase, or, for statins, change to a more potent formulation. Lipid and BP values were obtained at 12 months pre- and post-CTA. RESULTS: Patients were 50 ± 12 years of age (59% men), with 34%, 47%, and 33% on baseline statin, BP medication(s), and aspirin, respectively. Relative to patients without CAD (n = 617), patients with nonobstructive (n = 411) and obstructive CAD (n = 97) demonstrated significant intensification in unadjusted rates of statin (26%, 46%, and 46% of patients; p < 0.001), BP (11%, 21%, and 24%; p < 0.001), and aspirin therapies (9%, 29%, and 40%; p < 0.001), and significant improvements in total cholesterol (-6.7, -14.7, and -24.7 mg/dl; p = 0.008), low-density lipoprotein cholesterol (-5.6, -14.1, and -24.6 mg/dl; p = 0.001), systolic (+0.1, -1.4, and -4.9 mm Hg; p = 0.002), and diastolic BP (-0.6, -1.0, and -3.4 mm Hg; p = 0.012), respectively. Adjusted for baseline risk factors and medications, CAD was independently associated with increased aspirin, statin, and BP medication use rates in CTA-identified nonobstructive CAD (odds ratio [OR]: 6.9, 95% confidence interval [CI]: 4.7 to 10.2; OR: 6.6, 95% CI: 3.0 to 14.3; OR: 1.6, 95% CI: 1.1 to 2.2, respectively; p < 0.05), and aspirin and statin use in obstructive CAD (OR: 42.4, 95% CI: 15.8 to 113.9; OR: 30.3, 95% CI: 3.2 to 289.2, respectively; p < 0.05). CONCLUSIONS: CAD presence and severity on CTA are associated with increased use of preventive cardiovascular medications and improvements in cholesterol and BP.

Prognostic value of coronary computed tomographic angiography among 1,125 consecutive military health care beneficiaries without known coronary artery disease.

We sought to assess the prognostic value of coronary computed tomography angiography (CCTA) among military health care system beneficiaries. We identified 1,125 consecutive symptomatic patients without known coronary artery disease (CAD) referred for 64-slice CCTA (2006-2010) at a single center. CAD was assessed as none, < 50%, or > or = 50% (obstructive) coronary stenosis. A combined endpoint of major adverse events (death, myocardial infarction [MI], coronary revascularization > 90 days after CCTA) was assessed by Kaplan-Meier and Cox proportional hazards. The mean age was 50 +/- 12 years, 59% were male, and 617 (55%) had no CAD, 411 (37%) nonobstructive CAD, and 97 (9%) obstructive CAD on CCTA. During 2.0 +/- 1.1-year follow-up, there were 6 deaths, 3 MIs, and 6 revascularizations. There was 1 event in the no-CAD group (0.08%/year), 4 events in the nonobstructive group (0.5%/year), and 9 events in patients with obstructive CAD (4.5%/year) (p < 0.001). Patients with obstructive CAD had significantly increased combined adverse events. Increasing angina typicality and risk factors (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.05-1.46; p = 0.01) and obstructive CAD (HR 12.1, 95% CI 3.99-36.9; p < 0.001) were independently predictive of events. Absence of CAD was associated with very low event rates, providing military health care system patients and providers confidence in regards to cardiovascular risk, future deployments, and occupational assignments.

Mercy health promoters: a paradigm for implementing third world practices for resource-poor conditions of the developed world.

The foreign-born population in the United States, according to the "Current Populations Report" published in 2004, is estimated to exceed 33.5 million, or "11.7 percent of the U.S. population". The increase in foreign-born peoples and their need for health care is a complicated issue facing many cities, health systems and hospitals. Over the course of the past few years Mercy Hospital of Philadelphia has treated increasing numbers of foreign-born African patients. The majority have been presenting in the late stages of disease. The increase of foreign-born documented and undocumented African patients seen by Mercy Hospital seems to reflect a foreign-born population "boom" in Philadelphia over the past decade. To meet the needs of this growing population, the Mercy Hospital Task Force on African Immigration designed a program that centers on the developing world concept of "Health Promoters". This program is intended to serve as one possible solution for hospitals to cost-effectively manage the care of this growing percentage of foreign-born individuals in the population. This notion of a "Health Promoter" program in Philadelphia is unique as one of those rare occasions when a developing world concept is being utilized in a developed world environment. It is also unique in that it can serve as a paradigm for other hospitals in the United States to meet the growing need of health care for the undocumented population.