Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research.

From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.

Empowering Third-Year Medical Students to Detect Bias and Medical Misinformation Online via Experiential Learning of "Lateral Reading," A Fact-Checker's Technique.

Problem: Misleading health information is detrimental to public health. Even physicians can be misled by biased health information; however, medical students and physicians are not taught some of the most effective techniques for identifying bias and misinformation online. Intervention: Using the stages of Kolb's experiential learning cycle as a framework, we aimed to teach 117 third-year students at a United States medical school to apply a fact-checking technique for identifying bias and misinformation called "lateral reading" through a 50-minute learning cycle in a 90-minute class. Each student's concrete experience was to independently read a biased article and rate its credibility, demonstrating their baseline skills at identifying bias. Students were given structured opportunities for reflective observation through individual and large group discussion. Students were guided through abstract conceptualization to determine techniques and frameworks utilized by fact checkers, specifically "lateral reading"-utilizing the internet to research the background of the author, organization, and citations using independent sources before exploring the article itself in depth. Students' active experimentation included re-rating the credibility of the same article and discussing further implications with classmates and instructors. Context: In January 2020, sessions were offered to third-year medical students during their required, longitudinal transition-to-residency course. Impact: Compared to baseline, when using lateral reading, students deemed the article less credible. Students' active experimentation changed whether they identified the organization and sources behind the article as credible. Notably, 86% (53/62) of students who viewed the organization positively pre-intervention did not describe the organization positively post intervention. Similarly, 66% (36/55) of students who cited the sources as positive pre-exercise changed their assessment after the exercise. While three students mentioned the author negatively pre-intervention, none of the 21 students who described the author in a negative fashion post-intervention described the author negatively pre-intervention. Positively describing the organization, author, or sources pre-intervention correlated with differences in credibility rating after the intervention. These findings indicate that teaching students to read laterally may increase their ability to detect bias in online medical information. Lessons Learned: Further research is needed to determine whether students who learned lateral reading via experiential learning will apply this skill in their education and career. Additionally, research should assess whether this skill helps future physicians counter bias and misinformation in ways that improve health.

Patient Heterogeneity and the J-Curve Relationship Between Time-to-Antibiotics and the Outcomes of Patients Admitted With Bacterial Infection.

OBJECTIVES: Sepsis remains a leading and preventable cause of hospital utilization and mortality in the United States. Despite updated guidelines, the optimal definition of sepsis as well as optimal timing of bundled treatment remain uncertain. Identifying patients with infection who benefit from early treatment is a necessary step for tailored interventions. In this study, we aimed to illustrate clinical predictors of time-to-antibiotics among patients with severe bacterial infection and model the effect of delay on risk-adjusted outcomes across different sepsis definitions. DESIGN: A multicenter retrospective observational study. SETTING: A seven-hospital network including academic tertiary care center. PATIENTS: Eighteen thousand three hundred fifteen patients admitted with severe bacterial illness with or without sepsis by either acute organ dysfunction (AOD) or systemic inflammatory response syndrome positivity. MEASUREMENTS AND MAIN RESULTS: The primary exposure was time to antibiotics. We identified patient predictors of time-to-antibiotics including demographics, chronic diagnoses, vitals, and laboratory results and determined the impact of delay on a composite of inhospital death or length of stay over 10 days. Distribution of time-to-antibiotics was similar across patients with and without sepsis. For all patients, a J-curve relationship between time-to-antibiotics and outcomes was observed, primarily driven by length of stay among patients without AOD. Patient characteristics provided good to excellent prediction of time-to-antibiotics irrespective of the presence of sepsis. Reduced time-to-antibiotics was associated with improved outcomes for all time points beyond 2.5 hours from presentation across sepsis definitions. CONCLUSIONS: Antibiotic timing is a function of patient factors regardless of sepsis criteria. Similarly, we show that early administration of antibiotics is associated with improved outcomes in all patients with severe bacterial illness. Our findings suggest identifying infection is a rate-limiting and actionable step that can improve outcomes in septic and nonseptic patients.

The impact of clinical uncertainty in the graduate medical education (GME) learning environment: A mixed-methods study.

BACKGROUND: Uncertainty is ubiquitous in medicine. Studies link intolerance of uncertainty to burnout, ineffective communication, cognitive bias, and inappropriate resource use. Little is known about how uncertainty manifests in the clinical learning environment. We aimed to explore the perceptions and experiences of uncertainty among residents and attendings. METHODS: We conducted a mixed-methods study including a survey, semi-structured interviews, and ethnographic observations during rounds with residents and attendings at an academic medical center. The survey included three validated instruments: Physicians' Reaction to Uncertainty Scale; Maslach Burnout Inventory 2-item; and Educational Climate Inventory. RESULTS: 35/60 (58%) of eligible residents and 14/21 (67%) attendings completed the survey. Residents reported higher anxiety due to uncertainty than attendings, higher concern about bad outcomes, and greater reluctance to disclose uncertainty to patients. Residents reported increased symptoms of burnout (p < .05). Perceiving the learning environment as more competitive correlated with reluctance to disclose uncertainty (r = -0.44; p < .01). Qualitative themes included: recognizing and facing uncertainty, and consequences for the learning environment. Observations revealed senior clinicians have greater comfort acknowledging uncertainty. CONCLUSIONS: Medical curricula should be developed to promote recognition and acknowledgement of uncertainty. Greater acknowledgement of uncertainty, specifically by attendings and senior residents, may positively impact the clinical learning environment.

Does an endocrinology subspecialty residency rotation enhance resident endocrine clinical knowledge?

BACKGROUND: Internal Medicine (IM) programs offer elective subspecialty rotations in which residents may enroll to supplement the experience and knowledge obtained during general inpatient and outpatient rotations. Objective evidence that these rotations provide enhanced subspecialty specific knowledge is lacking. The purpose of this study was to determine whether exposure to an endocrinology subspecialty rotation enhanced a resident's endocrinology-specific knowledge beyond that otherwise acquired during IM residency. METHODS: Data were collected on internal medicine resident scores on the American College of Physicians Internal Medicine In-Training Examinations (IM-ITE) for calendar years 2012 through 2018 along with enrollment data as to whether residents had completed an endocrinology subspecialty rotation prior to sitting for a given IM-ITE. Three hundred and six internal medicine residents in the University of Minnesota Internal Medicine residency program with 664 scores total on the IM-ITE for calendar years 2012 through 2018. Percentage of correct answers on the overall and endocrine subspecialty content areas on the IM-ITE for each exam were determined and the association between prior exposure to an endocrinology subspecialty rotation and percentage of correct answers in the endocrinology content area was analyzed using generalized linear mixed-effects models. RESULTS: Two hundred and thirty-three residents (76%) completed an endocrinology subspecialty rotation at some point during their residency; 121 (40%) residents had at least one IM-ITE both before and after exposure to an endocrine subspecialty rotation. Exposure to an endocrinology subspecialty rotation exhibited a positive association with the expected IM-ITE percent correct on the endocrinology content area (5.5% predicted absolute increase). Advancing year of residency was associated with a predicted increase in overall IM-ITE score but did not improve the predictive model for endocrine subspecialty score. CONCLUSIONS: Completion of an endocrinology subspecialty elective was associated with an increase in resident endocrine specific knowledge as assessed by the IM-ITE. These findings support the value of subspecialty rotations in enhancing a resident's subspecialty specific medical knowledge.

Measuring and Improving Diagnostic Safety in Primary Care: Addressing the "Twin" Pandemics of Diagnostic Error and Clinician Burnout.

Diagnostic errors are a source of unacceptable harm in health care. However, improvement efforts have been hampered by the lack of valid measures reflecting the quality of the diagnostic process. At the same time, it has become apparent that the healthcare work system, particularly in primary care, is chaotic and stressful, leading to clinician burnout and patient harm. We propose a new construct that health systems and researchers can use to measure the quality and safety of the diagnostic process that is sensitive to the context of the health care work system. This model focuses on three measurable practices: considering "don't miss" diagnoses, looking for red flags, and ensuring that clinicians avoid common diagnostic pitfalls. We believe that the performance of clinicians with respect to these factors is sensitive to the health care work system, allowing for context-dependent measurement and improvement of the diagnostic process. Such process measures will enable more rapid improvements rather than exclusively measuring outcomes related to "correct" or "incorrect" diagnoses.

The critical need for nursing education to address the diagnostic process.

Diagnostic errors are among the most common medical errors and the deadliest. The National Academy of Medicine recently concluded that diagnostic errors represent an urgent national concern. Their first recommendation to address this issue called for promoting the key role of the nurse in the diagnostic process. Registered nurses across clinical settings significantly contribute to the medical diagnostic process, though their role in diagnosis has historically gone unacknowledged. In this paper, we review the history and current state of diagnostic education in pre-licensure registered nurse preparation, introduce interprofessional individual- and team-based competencies to improve diagnostic safety, and discuss the next steps for nursing education. Nurses educated and empowered to fully participate in the diagnostic process are essential for achieving better, safer patient outcomes.

Hospitalist-Operated Compression Ultrasonography: a Point-of-Care Ultrasound Study (HOCUS-POCUS).

BACKGROUND: Venous thromboembolism includes deep vein thrombosis (DVT) and pulmonary embolism. Compression ultrasonography is the most common way to evaluate DVT and is typically performed by sonographers and interpreted by radiologists. Yet there is evidence that ultrasound examinations can be safely and accurately performed by clinicians at the bedside. OBJECTIVE: To measure the operating characteristics of hospital medicine providers performing point-of-care ultrasound (POCUS) for evaluation of DVT. DESIGN: This is a prospective cohort study enrolling a convenience sample of patients. Hospital medicine providers performed POCUS for DVT and the results were compared with the corresponding formal vascular study (FVS) interpreted by radiologists. PARTICIPANTS: Hospitalized non-ICU patients at four tertiary care hospitals for whom a DVT ultrasound was ordered. MAIN MEASURES: The primary outcomes were the sensitivity, specificity, and predictive values of the POCUS compression ultrasound compared with a FVS. The secondary outcome was the elapsed time between order and the POCUS study compared with the time the FVS was ordered to when the formal radiology report was finalized. KEY RESULTS: One hundred twenty-five limbs from 73 patients were scanned. The prevalence of DVT was 6.4% (8/125). The sensitivity of POCUS for DVT was 100% (95% CI 74-100%) and specificity was 95.8% (95% CI 91-98%) with a positive predictive value of 61.5% (95% CI 35-84%) and a negative predictive value of 100% (95% CI 98-100%). The median time from order to POCUS completion was 5.8 h versus 11.5 h median time from order until the radiology report was finalized (p = 0.001). CONCLUSION: Hospital medicine providers can perform compression-only POCUS for DVT on inpatients with accuracy similar to other specialties and settings, with results available sooner than radiology. The observed prevalence of DVT was lower than expected. POCUS may be reliable in excluding DVT but further study is required to determine how to incorporate a positive POCUS DVT result into clinical practice.

Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events.

Diagnostic error is a prevalent, harmful, and costly phenomenon. Multiple national health care and governmental organizations have recently identified the need to improve diagnostic safety as a high priority. A major barrier, however, is the lack of standardized, reliable methods for measuring diagnostic safety. Given the absence of reliable and valid measures for diagnostic errors, we need methods to help establish some type of baseline diagnostic performance across health systems, as well as to enable researchers and health systems to determine the impact of interventions for improving the diagnostic process. Multiple approaches have been suggested but none widely adopted. We propose a new framework for identifying "undesirable diagnostic events" (UDEs) that health systems, professional organizations, and researchers could further define and develop to enable standardized measurement and reporting related to diagnostic safety. We propose an outline for UDEs that identifies both conditions prone to diagnostic error and the contexts of care in which these errors are likely to occur. Refinement and adoption of this framework across health systems can facilitate standardized measurement and reporting of diagnostic safety.

Point-of-Care Ultrasound Improves Shared Diagnostic Understanding Between Patients and Providers.

OBJECTIVES: Point-of-care ultrasound (POCUS) has become an integral part of the physical examination. The effect on shared understanding of adding POCUS to the traditional examination is unknown, yet this is an often-described benefit of POCUS. The primary aim of this study was to determine whether the use of POCUS improves shared understanding between providers and patients about patients' diagnoses. METHODS: This was a prospective controlled trial involving a convenience sample of hospitalized adults. Providers in the control arm performed usual care without POCUS, whereas providers in the study arm had the option to add POCUS. Surveys were administered to the subjects and their providers with questions on patient understanding of symptoms, diagnosis, and main contributors to their health problem. Two independent physicians rated the degree of shared understanding between patient and provider surveys. RESULTS: Of the 64 patients enrolled in the study, 60 had complete data. There was increased shared understanding between providers and patients with respect to their diagnosis (POCUS 9.56 ± 0.63, non-POCUS 7.62 ± 1.63, P < 0.005) and main contributors (POCUS 9.65 ± 0.77, non-POCUS 8.30 ± 1.13, P < 0.005) in the POCUS arm compared with the non-POCUS arm. Patients also increased the self-rating of their understanding of their health problem in the POCUS arm. CONCLUSIONS: These findings suggest that using POCUS improves patients' understanding of the diagnostic process. POCUS may be uniquely poised to enhance patients' understanding of and engagement in that process.

Entrusting internal medicine residents to use point of care ultrasound: Towards improved assessment and supervision.

Background: Internal medicine physicians and trainees are increasingly using, and seeking training in, diagnostic point of care ultrasound (POCUS). Numerous internal medicine training programs have described their curricula, but little has been written about how learners should be assessed, supervised, and allowed to progress toward independent practice, yet these practices are imperative for safe and effective use. Entrustable professional activities (EPAs) offer a practical method to assess observable units of professional work and make supervision decisions. Methods: An EPA for POCUS is used as a framework to assess and determine appropriate levels of supervision in an internal medicine residency program. Results: All learners have been able to advance to level 2 with a mandatory introductory boot camp course. Learners have been able to advance to higher levels of independence, often after taking formal elective programmatic coursework. However, not all learners taking the same coursework have been granted the same level of independence. Conclusions: It is feasible to assess and supervise internal medicine residents' ability to use diagnostic point of care ultrasound using an EPA.

Running Out of Options: Rhabdomyolysis Associated with Cannabis Hyperemesis Syndrome.

Cannabis hyperemesis syndrome (CHS) is a condition in which some patients with long-term, frequent use of cannabis paradoxically develop recurrent episodes of nausea and vomiting. The pathophysiology underlying this condition is poorly understood, as is the explanation for its common association with patients' discovery that hot-water bathing alleviates symptoms. We describe the case of a 24-year-old male with daily marijuana use and a history of CHS who was found to have rhabdomyolysis induced by a period of 15 h of continuous jogging after he discovered that this activity helped to alleviate his symptoms. To our knowledge, this is the first reported case of exercise-alleviated CHS symptoms, and we propose that this case provides support to the theory of redistribution of enteric blood flow as the mechanism behind the learned hot-water bathing behavior seen so commonly in CHS.

Digital supervision in the clinical learning environment: Characterizing teamwork in the electronic health record.

BACKGROUND: Attending physicians in academic hospitals work in supervisory team structures with medical residents to provide patient care. How attendings utilize the electronic health record (EHR) to support learning through supervision is not well understood. OBJECTIVE: To compare EHR behavior on teaching versus direct care, including evidence of supervisory calibration to learners. METHODS: Cross-sectional study analysis of EHR metadata from 1721 shifts of hospital medicine faculty at a large, urban academic medical center, January to June 2022. Measures included total EHR time per shift, EHR time outside shift, and time spent on: note-writing, note review/attestation, order entry, and other clinical review. We assessed within physician differences across these service types and used multilevel modeling to determine whether these behaviors varied with resident physicians' experience, accounting for physician-specific signature behavior patterns. RESULTS: Attendings spent substantially less time in the EHR while on teaching service than on direct service (129 vs. 240 min; p < .001) and apportioned their work differently throughout the day. Physicians were less behaviorally consistent and varied more than their peers when on teaching service. Attendings calibrated their supervision to learners. Attendings logged 12.7% less EHR time when paired with more senior residents than postgraduate year 2 (PGY2) residents (137 vs. 120 min, p = .002). PGY1 presence was also associated with reduced EHR time, suggesting some delegation of supervision to senior trainees. CONCLUSION: EHR behaviors on teaching service are highly variable and differ substantially from direct care; a lack of consistency suggests important opportunities to establish best practices for EHR-based supervision and create an effective clinical learning environment.

Gender differences in factors associated with rural health care practice in Minnesota.

PURPOSE: To understand gender differences in factors affecting rural health care workforce to inform the development of effective policies and recruitment strategies to address rural health care workforce shortages. METHODS: A cross-sectional survey of health care professionals (including Advanced practice registered nurses (APRNs), physicians, physician assistants (PAs), and registered nurses (RNs)) in Minnesota was administered by the Minnesota Department of Health from October 18, 2021, to July 25, 2022, during their professional license renewal. The main outcome was whether or not the respondent was practicing in a rural area. The effects of factors associated with rural practice were estimated using binary logistic regression models, and subsequently subgroup analysis was conducted by gender across the four health care professions. FINDINGS: Results show that although there were significant gender differences in some factors (growing up in a rural area and family considerations were more likely to influence women's decisions than men's, whereas men were more likely to be influenced by the prospect of having autonomy and broad scope of practice than women), these differences became insignificant when the four health care professionals were analyzed separately suggesting that overall gender differences observed were almost entirely explained by profession differences. CONCLUSIONS: Gender differences do not significantly influence the factors impacting rural practice. However, being raised in a rural environment emerges as the most influential predictor of rural practice underscoring the importance of involving rural residents of all genders in health care practice.