Clinical Reasoning: A 24-Year-Old Man With Gait Impairment, Hearing Loss, and Recurrent Fever.

We present a case study of a 24-year-old man who reported mild balance and walking difficulties for 2 years. He had a history of recurrent fever, skin lesions, headache, and elbow pain, but most of these events resolved spontaneously. There was no significant family history. On examination, we observed frontal bossing, sensorineural hearing loss, and gait ataxia. This case underscores the significance of identifying clinical indicators in patients with neurologic symptoms, particularly recurrent fever, to establish a precise and thorough differential diagnosis.

Embracing ChatGPT for Medical Education: Exploring Its Impact on Doctors and Medical Students.

ChatGPT (OpenAI), a cutting-edge natural language processing model, holds immense promise for revolutionizing medical education. With its remarkable performance in language-related tasks, ChatGPT offers personalized and efficient learning experiences for medical students and doctors. Through training, it enhances clinical reasoning and decision-making skills, leading to improved case analysis and diagnosis. The model facilitates simulated dialogues, intelligent tutoring, and automated question-answering, enabling the practical application of medical knowledge. However, integrating ChatGPT into medical education raises ethical and legal concerns. Safeguarding patient data and adhering to data protection regulations are critical. Transparent communication with students, physicians, and patients is essential to ensure their understanding of the technology's purpose and implications, as well as the potential risks and benefits. Maintaining a balance between personalized learning and face-to-face interactions is crucial to avoid hindering critical thinking and communication skills. Despite challenges, ChatGPT offers transformative opportunities. Integrating it with problem-based learning, team-based learning, and case-based learning methodologies can further enhance medical education. With proper regulation and supervision, ChatGPT can contribute to a well-rounded learning environment, nurturing skilled and knowledgeable medical professionals ready to tackle health care challenges. By emphasizing ethical considerations and human-centric approaches, ChatGPT's potential can be fully harnessed in medical education, benefiting both students and patients alike.

Storylines of family medicine VIII: clinical approaches.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VIII: clinical approaches', authors address the following themes: 'Evaluation, diagnosis and management I-toward a working diagnosis', 'Evaluation, diagnosis and management II-process steps', 'Interweaving integrative medicine and family medicine', 'Halfway-the art of clinical judgment', 'Seamless integration in family medicine-team-based care', 'Technology-uncovering stories from noise' and 'Caring for patients with multiple long-term conditions'. May readers recognise in these essays the uniqueness of a family medicine approach to care.

CRISP: An Inpatient Pediatric Curriculum for Family Medicine Residents Using Clinical Reasoning and Illness Scripts.

Introduction: Clinical reasoning enables safe patient care and is an important competency in medical education but can be challenging to teach. Illness scripts facilitate clinical reasoning but have not been used to create pediatric curricula. Methods: We created CRISP (Clinical Reasoning with Illness Scripts in Pediatrics), a curriculum comprising four 1-hour learning sessions that deliberately incorporated clinical reasoning concepts and illness scripts to organize how four common chief complaints were taught to family medicine residents on inpatient pediatric rotations. We performed a multisite curriculum evaluation project over 6 months with family medicine residents at four institutions to assess whether the use of clinical reasoning concepts to structure CRISP was feasible and acceptable for learners and instructors and whether the use of illness scripts increased knowledge of four common pediatric chief complaints. Results: For all learning sessions, family medicine residents and pediatric hospitalists agreed that CRISP's format was preferable to traditional didactic lectures. Pre-/posttest scores showed statistically significant increases in family medicine resident knowledge (respiratory distress [n = 42]: pretest, 72%, posttest, 92%; abdominal pain [n = 44]: pretest, 82%, posttest, 96%; acute febrile limp [n = 44]: pretest, 68%, posttest, 81%; well-appearing febrile infant [n = 42]: pretest, 58%, posttest, 73%; ps < .05). Discussion: By using clinical reasoning concepts and illness script comparison to structure a pediatric curriculum, CRISP represents a novel instructional approach that can be used by pediatric hospitalists to increase family medicine resident knowledge about diagnoses associated with common pediatric chief complaints.

The Lasater Clinical Judgment Rubric: 17 Years Later.

BACKGROUND: Nearly 17 years ago, the Lasater Clinical Judgment Rubric (LCJR) was published to provide a common language and trajectory of students' development to think like a nurse. METHOD: This article traces the uses of the LCJR from creation to the present and cites lessons learned from its use. RESULTS: During the intervening years, the LCJR has been used effectively as a debriefing guide in simulation and as a research instrument, as well as for formative assessment. The LCJR has been translated or is in process in 19 languages besides English. CONCLUSION: This article provides evidence of the efficacy of the LCJR and discusses important lessons learned. [J Nurs Educ. 2024;63(3):149-155.].

Evaluating the Importance of Clinical Judgment in Entry-Level Nursing.

BACKGROUND: This study investigated the extent to which clinical judgment is important in entry-level nursing practice. METHOD: A task analysis linkage study methodology based on a large-scale, comprehensive practice analysis was used for the study. The practice analysis validated more than 200 entry-level nursing tasks, and the linkage study sought to evaluate the importance of clinical judgment overall and for each specific task expectation. RESULTS: The results provide confirmatory evidence of the importance of clinical judgment. In addition, the work provides a comprehensive list of entry-level tasks and their associated clinical judgment importance. CONCLUSION: Clinical judgment is a vital skill at entry into the profession and is expected to grow over time. This study offers insights on the extent to which clinical judgment is a necessary skill and provides direct evidence of its importance for specific entry-level tasks. [J Nurs Educ. 2024;63(3):156-162.].

Reflective Clinical Judgment Questions to Educate the Next Generation of Nurses.

BACKGROUND: The complexity of health care requires entry-level nurses to have competent clinical judgment skills. In response, a nursing program created Reflective Clinical Judgment Questions (RCJQ) to guide students in the development of clinical judgment. METHOD: The RCJQ incorporates the Clinical Judgment Measurement Model, the National Council of State Boards of Nursing's action questions, and the American Association of Colleges of Nursing's core competencies for professional nursing education. The RCJQ includes cognitive process questions and self-reflection questions aligned to the prelicensure subcompetencies to direct student thinking and build a routine for clinical decision making. RESULTS: The RCJQ provides faculty with a framework to teach clinical judgment and incorporates self-reflective questions to guide decision making for safe and effective client care. CONCLUSION: The RCJQ streamlines the clinical judgment process and guides students to achieve essential outcomes in classroom, clinical, and simulation settings to prepare for clinical practice. [J Nurs Educ. 2024;63(3):182-185.].

Classroom Innovation Using the NCJMM: Preparing Nursing Students for the Next Generation NCLEX.

BACKGROUND: There is a growing demand for classroom creativity to increase engagement and build clinical judgment skills for nursing students. This article describes the design and implementation of an interactive classroom activity to enhance the development of clinical judgment while simultaneously orienting students to the new NCLEX Next Generation testing model. METHOD: Faculty developed an interactive unfolding case study incorporating the six dimensions of the NCSBN Clinical Judgment Measurement Model. The case study question types were adapted to use an interactive learning platform for first-year nursing students. Students' perceptions of learning, engagement, and clinical judgment were surveyed. RESULTS: Student responses regarding the case study implementation indicated this method was effective in maintaining engagement and persistence, as well as promoting nursing decision making. CONCLUSION: The time used for building innovative classroom activities is well spent to meet the objective of enhancing clinical judgment in the next generation of nursing students. [J Nurs Educ. 2024;63(3):188-191.].

The Use of QR Codes to Engage Nursing Students With Next Generation NCLEX.

BACKGROUND: The introduction of the Next Generation NCLEX (NGN) necessitates the need to prepare students to demonstrate appropriate clinical judgment and reasoning. Innovative teaching strategies, such as the use of QR codes, may help to engage learners and promote the transition to the new NCLEX testing format. METHOD: A three-phase pediatric-based case study was used to introduce NGN style questions. The QR codes provided resources, answers, and rationales for the case study questions. RESULTS: The students reported an increase in perceived confidence with a case study-based NGN testing item. Student feedback was positive for this active and collaborative learning experience. CONCLUSION: Nurse educators are challenged with finding methods to engage learners and prepare students for practice. Using QR codes in the classroom is an innovative approach to expose students to NGN questions and may help increase students confidence as they prepare for the new NGN. [J Nurs Educ. 2024;63(3):186-187.].

Collaborative clinical reasoning: a scoping review.

Background: Collaborative clinical reasoning (CCR) among healthcare professionals is crucial for maximizing clinical outcomes and patient safety. This scoping review explores CCR to address the gap in understanding its definition, structure, and implications. Methods: A scoping review was undertaken to examine CCR related studies in healthcare. Medline, PsychInfo, SciVerse Scopus, and Web of Science were searched. Inclusion criteria included full-text articles published between 2011 to 2020. Search terms included cooperative, collaborative, shared, team, collective, reasoning, problem solving, decision making, combined with clinical or medicine or medical, but excluded shared decision making. Results: A total of 24 articles were identified in the review. The review reveals a growing interest in CCR, with 14 articles emphasizing the decision-making process, five using Multidisciplinary Team-Metric for the Observation of Decision Making (MDTs-MODe), three exploring CCR theory, and two focusing on the problem-solving process. Communication, trust, and team dynamics emerge as key influencers in healthcare decision-making. Notably, only two articles provide specific CCR definitions. Conclusions: While decision-making processes dominate CCR studies, a notable gap exists in defining and structuring CCR. Explicit theoretical frameworks, such as those proposed by Blondon et al. and Kiesewetter et al., are crucial for advancing research and understanding CCR dynamics within collaborative teams. This scoping review provides a comprehensive overview of CCR research, revealing a growing interest and diversity in the field. The review emphasizes the need for explicit theoretical frameworks, citing Blondon et al. and Kiesewetter et al. The broader landscape of interprofessional collaboration and clinical reasoning requires exploration.

Knowledge, Attitude, and Practice (KAP) Status toward Clinical Reasoning and Evidence-Based Medicine among the Medical Interns and Gynecology Residents of Iran University of Medical Sciences.

Background: Clinical reasoning and evidence-based medicine (EBM) are important concepts in modern medicine. Objective: We performed this study to investigate the knowledge, attitude, and practice (KAP) status toward clinical reasoning and EBM among the medical interns and gynecology resident physicians of Iran University of Medical Sciences and related factors. Methods: A cross-sectional study (Tehran, Iran, first half of 2022) was conducted based on two researcher-made questionnaires consisting of three components for each including clinical reasoning attitude (CR-A), clinical reasoning knowledge (CR-K), clinical reasoning practice (CR-P), EBM attitude (EBM-A), EBM knowledge (EBM-K), and EBM practice (EBM-P). The related factors were age, gender, educational level, score of general practice education, having research experience, and general practice experience. Results: A total of 60 individuals participated. The mean score was good for CR-A, moderate for CR-K, moderate for CR-P, good for EBM-A, moderate for EBM-K, and moderate for EBM-P. The total score was moderate in both clinical reasoning and EBM. Among the related factors, CR-P was associated with higher educational levels and having experience in general practice (P < 0.05). Research experience was associated with better CR-K and all KAP components for EBM (P < 0.05). Conclusion: The total score and many of the KAP components had moderate status for clinical reasoning and EBM. Planning on the associated factors should be regarded in the future. Such questionnaires are suggested to be validated for use in quasi-experimental studies.

Can ChatGPT pass the MRCP (UK) written examinations? Analysis of performance and errors using a clinical decision-reasoning framework.

OBJECTIVE: Large language models (LLMs) such as ChatGPT are being developed for use in research, medical education and clinical decision systems. However, as their usage increases, LLMs face ongoing regulatory concerns. This study aims to analyse ChatGPT's performance on a postgraduate examination to identify areas of strength and weakness, which may provide further insight into their role in healthcare. DESIGN: We evaluated the performance of ChatGPT 4 (24 May 2023 version) on official MRCP (Membership of the Royal College of Physicians) parts 1 and 2 written examination practice questions. Statistical analysis was performed using Python. Spearman rank correlation assessed the relationship between the probability of correctly answering a question and two variables: question difficulty and question length. Incorrectly answered questions were analysed further using a clinical reasoning framework to assess the errors made. SETTING: Online using ChatGPT web interface. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was the score (percentage questions correct) in the MRCP postgraduate written examinations. Secondary outcomes were qualitative categorisation of errors using a clinical decision-making framework. RESULTS: ChatGPT achieved accuracy rates of 86.3% (part 1) and 70.3% (part 2). Weak but significant correlations were found between ChatGPT's accuracy and both just-passing rates in part 2 (r=0.34, p=0.0001) and question length in part 1 (r=-0.19, p=0.008). Eight types of error were identified, with the most frequent being factual errors, context errors and omission errors. CONCLUSION: ChatGPT performance greatly exceeded the passing mark for both exams. Multiple choice examinations provide a benchmark for LLM performance which is comparable to human demonstrations of knowledge, while also highlighting the errors LLMs make. Understanding the reasons behind ChatGPT's errors allows us to develop strategies to prevent them in medical devices that incorporate LLM technology.

Clinical Reasoning: A 19-Month-Old Girl With Infantile-Onset Myopathy and White Matter Changes.

We describe the case of a 19-month-old girl presenting with gross motor delays, hypotonia, diminished deep tendon reflexes, hyperCKaemia, extensive white matter changes on MRI brain, and electromyography studies consistent with myopathy. The differential diagnosis for infantile-onset hypotonia and muscle weakness is broad. It includes numerous subtypes of genetic disorders, including congenital muscular dystrophies, congenital myopathies, congenital myasthenic syndromes, spinal muscular atrophy, single-gene genetic syndromes, and inborn errors of metabolism. We outline our clinical approach leading to the diagnosis of a distinctive genetic neuromuscular condition essential for neurologists and geneticists working with patients of all ages to recognize.

Evaluating clinical reasoning in first year DPT students using a script concordance test.

BACKGROUND: A script concordance test (SCT) provides a series of clinical vignettes to assess clinical reasoning in uncertainty. Appraised throughout health education literature, SCTs are cognitive assessments of clinical reasoning, though their use in Doctor of Physical Therapy (DPT) entry-level education has not been investigated. The purpose of this study was to develop and explore the reliability and validity of a SCT for first year DPT students. METHODS: The SCT was developed and implemented over four phases. During phases one and two, DPT program faculty consulted on course content from the first-year curriculum. Thirty clinical vignettes with three follow-up questions each were constructed. The SCT was pilot tested with five clinicians in phase three to assess question clarity. During phase four, the SCT was administered to students and a reference panel via Qualtrics. First year DPT students (n = 44) and reference panel physical therapists with at least two years of experience and advanced certification (n = 15) completed the SCT. Internal consistency was analyzed using Cronbach's Alpha. Differences between student and reference panel percent-correct scores were analyzed with a t-test. Relationships between student SCT scores and academic records were explored with Spearman's Rho. RESULTS: The SCT had an internal consistency of 0.74. A significant difference in scores was found between the students [mean 58.5 (+/-5.31)] and reference panel [65.8 (+/-4.88), p < .01]. No significant correlations between student SCT scores and academic records were found. CONCLUSIONS: The developed SCT was reliable and demonstrated satisfactory internal consistency among test items. The SCT successfully differentiated between groups, with the reference panel demonstrating statistically significant higher percent-correct scores compared to students. SCTs may provide means to measure clinical reasoning in DPT students and lead to novel pedagogical approaches to enhance clinical reasoning.

The prevalence, clinical reasoning and impact of non-standard anti-tuberculosis regimens at the initial prescription.

Regarding clinically-concerning non-standard initial anti-tuberculous (TB) regimens, few studies have examined their prevalence, risk factors and impacts. We recruited patients with drug susceptible TB and non-standard initial anti-TB regimens (NSTB group) and matched them with patients with standard initial regimens (STB group) in a 1:1 ratio. The risk factors and outcomes were analyzed. During the 11-year study period, we analyzed 50 (3.7%) patients with NSTB from a total set of 1337 patients with drug-susceptible TB. Pyrazinamide (60%) was the drug most commonly not prescribed in the NSTB group, followed by ethambutol (34%). Multivariable logistic regression identified independent risk factors as underlying eye disease (adjusted odds ratio [aOR]: 8.869; 95% CI 2.542-30.949; p = 0.001), gout/hyperuricemia (aOR: 4.012 [1.196-13.425]; p = 0.024), and liver disease (aOR: 12.790 [3.981-41.089]; p < 0.001). The NSTB group had longer treatment durations (281 ± 121 vs. 223 ± 63 days; p = 0.003) and more occurrences of treatment interruption (26% vs. 8%; p = 0.021) than the STB group. In conclusion, NSTB occurs in around 3.7% of patients and is associated with longer treatment and more treatment interruption. The risk factors might include underlying liver and eye diseases, and gout. Further studies to improve non-standard initial regimens and prevent negative outcomes are warranted.

The effect of case-based mobile virtual patient application on students' academic achievement in clinical reasoning skills.

This mixed-method study aims to determine the effect of the use of mobile virtual patient application with narrated case-based virtual patients as an assistive technology on students' clinical reasoning skills. It makes a notable contribution by exploring the impact of mobile virtual patient applications on healthcare students' clinical skills and their preparation for real-world patient care. In addition, the accuracy of the analysis results regarding the effect on student achievement was analyzed with a second dataset tool, and thus, aiming to increase reliability by verifying the same research question with a different quantitative analysis technique. In the qualitative part of the study, students' views on the implementation were collected through an open-ended questionnaire and the data were subjected to content analysis. An achievement test was also developed to determine the development of students' clinical reasoning skills, which revealed that each of the learning environments had different outcomes regarding students' achievement and that supporting the traditional environment with the mobile virtual patient application yielded better results for increasing students' achievement. Students' opinions about the mobile virtual patient application and the process also support the increase in academic achievement aimed at measuring clinical reasoning skills. The content analysis showed that the students, who generally reported multiple positive factors related to the application, thought that the stories and cases presented created a perception of reality, and they especially highlighted the contribution of the application to learning the story organization. Based on all these results, it can be said that the application supports clinical reasoning, provides practical experience, improves academic achievement, and contributes positively to motivation.

[Clinical Judgement and Relational Competence in the Psychotherapy of Older Patients]. / Klinische Urteilsbildung und Beziehungskompetenz in der Psychotherapie älterer PatientInnen.

The negative attitude of psychotherapists towards the treatment of older patients in the past has weakened in the recent past. Nevertheless, the question remains as to how therapists perceive older patients in comparison to younger patients, what clinical judgements they arrive at and how they perceive the relationship with them. In the present study, which was conducted as part of the ÄPP study (Older Patients in Psychotherapy), therapists were asked to assess a self-selected younger (<40 years) or an older patient (>65) with regard to various variables. A total of 527 completed questionnaires were available. Two-factor analyses of variance were used to show, among other things, that younger therapists (compared to their older colleagues) rate older patients more negatively in terms of suitability for psychotherapy, the patient's ability to establish a therapeutic working relationship and other parameters. In comparison with their older colleagues, younger therapists perceive themselves as less competent in their relationships with older patients. There are only slight differences with younger patients.