Clinical Reasoning in the Ward Setting: A Rapid Response Scenario for Residents and Attendings.

Introduction: There is a need for educational resources supporting the practice and assessment of the complex processes of clinical reasoning in the inpatient setting along a continuum of physician experience levels. Methods: Using participatory design, we created a scenario-based simulation integrating diagnostic ambiguity, contextual factors, and rising patient acuity to increase complexity. Resources include an open-ended written exercise and think-aloud reflection protocol to elicit diagnostic and management reasoning and reflection on that reasoning. Descriptive statistics were used to analyze the initial implementation evaluation results. Results: Twenty physicians from multiple training stages and specialties (interns, residents, attendings, family physicians, internists, surgeons) underwent the simulated scenario. Participants engaged in clinical reasoning processes consistent with the design, considering a total of 19 differential diagnoses. Ten participants provided the correct leading diagnosis, tension pneumothorax, with an additional eight providing pneumothorax and all participants offering relevant supporting evidence. There was also good evidence of management reasoning, with all participants either performing an intervention or calling for assistance and reflecting on management plans in the think-aloud. The scenario was a reasonable approximation of clinical practice, with a mean authenticity rating of 4.15 out of 5. Finally, the scenario presented adequate challenge, with interns and residents rating it as only slightly more challenging (means of 7.83 and 7.17, respectively) than attendings (mean of 6.63 out of 10). Discussion: Despite the challenges of scenario complexity, evaluation results indicate that this resource supports the observation and analysis of diagnostic and management reasoning of diverse specialties from interns through attendings.

Fasciotomy Improvement Through Recognition of Errors Course: A Focused Needs Assessment for Error Management Training for Lower Extremity Fasciotomy Performance.

BACKGROUND: Many injuries from recent wars involve extremity trauma secondary to blasts, which predispose patients to developing extremity compartment syndrome. In military studies, 17% of fasciotomies required revision on arrival to a Role 4 hospital, and 41% of these had missed compartments, which is similar to that seen in civilian centers. While training has decreased this rate to 8%, this number is still too high. We conducted a focused needs assessment to guide the development of lower-extremity fasciotomy training. METHODS: In a predeployment assessment, 42 military surgeons performed a 2-incision, 4-compartment, lower-extremity fasciotomy on simulated lower leg models. Models were assessed for standardized and objectively-assessed major (inadequate skin or fascial incisions, missed compartments) and minor (failure to make an H-shaped incision over the lateral compartments, division of the greater saphenous vein) errors based on joint Trauma System clinical practice guidelines and approved training curricula. RESULTS: Four of 42 (9.5%) models contained no errors. Models averaged 4.3 ± 2.6 major and 0.3 ± 0.5 minor errors. 11 models (26.2%) had at least one missed compartment. The most common missed compartments were the deep posterior (17%) and anterior (14%). 29 (69%) had inadequate or poorly-placed skin incisions, with the most common being inadequate distal extension of the medial (10, 24%) and lateral (14, 33%) incisions, inadequate proximal extension of the lateral incision (6, 14%), medial incision too close to the tibia (7, 17%), and lateral incision over or behind the fibula (12, 29%). A total of 36 (86%) had inadequate fascial incisions. Inadequate fasciotomies were seen in the anterior (57%), lateral (55%), superficial (52%), and deep (34%) posterior compartments CONCLUSIONS: Performance on the models approximates what has been seen in military and civilian settings. This needs assessment will inform development of a simulation curriculum based on error-management and mastery learning theory to reduce the morbidity of lower-extremity compartment syndrome.

The SAGES flexible endoscopy course for fellows: a worthwhile investment in furthering surgical endoscopy.

BACKGROUND: The SAGES flexible endoscopy course for minimally invasive surgery (MIS) fellows improves confidence and skills in performing gastrointestinal (GI) endoscopy. This study evaluated the long-term retention of these confidence levels and investigated how fellows changed practices within their fellowships due to the course. METHODS: Participating MIS fellows completed surveys 6 months after the course. Respondents rated their confidence to independently perform 16 endoscopic procedures (1 = not at all; 5 = very), barriers to use of endoscopy, and current uses of endoscopy. Respondents also noted participation in additional skills courses and status of fundamentals of endoscopic surgery (FES) certification. Comparisons of responses from the immediate post-course survey to the 6-month follow-up survey were examined. McNemar and paired t tests were used for analyses. RESULTS: 23 of 57 (40%) course participants returned to the 6-month survey. No major barriers to endoscopy use were identified. Fellows reported less competition with GI providers as a barrier to practice compared to their original post-course expectations (50% vs. 86%, p < 0.01). In addition, confidence was maintained in performing the majority of the 16 endoscopic procedures, although fellows reported significant decreases in confidence in independently performing snare polypectomy (- 26%; p < 0.05), control of variceal bleeding (- 39%; p < 0.05), colonic stenting (- 48%; p < 0.01), BARRX (- 40%; p < 0.05), and TIF (- 31%; p < 0.05). Fewer fellows used the GI suite to manage surgical problems than was anticipated post course (26% vs. 74%, p < 0.01). Fellows who passed FES noted no significant loss of independence, changes in use, or barriers to use. 18% made additional partnerships with industry after the course. 41% stated flexible endoscopy has influenced their post-fellowship job choice. CONCLUSIONS: The SAGES flexible endoscopy course for MIS fellows results in long-term practice changes with participating fellows maintaining confidence to perform the majority of taught endoscopic procedures 6 months later. Additionally, fellows experienced no major barriers to implementing endoscopy into practice.