New education method or tool
Open Access

A Novel Clinical Reasoning Coaching Program for the Medicine Learner in Need

Andrew Parsons[1][a], Karen Warburton[1]

Institution: 1. University of Virginia
Corresponding Author: Dr Andrew Parsons ([email protected])
Categories: Assessment, Educational Strategies, Students/Trainees, Clinical Skills, Undergraduate/Graduate
Published Date: 10/01/2019

Abstract

Background: Clinical reasoning deficits are common among medical trainees. Assessment of clinical reasoning skills is challenging, and limited evidence is available to guide remediation practices.

 

Objective: We identified graduate medical learners struggling with clinical reasoning within the University of Virginia (UVA) Department of Medicine (DOM) and referred them for structured remediation. 

 

Methods: In 2016, we implemented a three phase remediation program for struggling graduate medical learners. Learners were referred to a remediation specialist who performed a standardized global assessment and identified a primary clinical deficit in one of the following areas: medical knowledge, clinical reasoning, organization/efficiency, and professionalism. Those with a primary clinical reasoning deficit were referred to a clinical reasoning coach to participate in a novel remediation program comprised of a 10-step, case-based targeted assessment followed by coaching of the clinical reasoning deficit(s) along the following spectrum: hypothesis generation; data gathering; problem representation; illness script organization; and appropriate manipulation of the differential diagnosis. Learners then engaged in direct observation exercises with supervising faculty.

 

Results: Remediation plans were implemented for twelve resident and fellow learners (5% of total learners) in the DOM. Clinical reasoning was the most commonly identified deficit (8/14 referred learners). Targeted assessment of these learners revealed deficits in the following domains of clinical reasoning: hypothesis generation (5/8), data gathering (2/8), problem representation (6/8), illness script knowledge and organization (2/8), and appropriate manipulation of the differential diagnosis (7/8).  Following completion, all learners are currently in good standing in their respective programs.

 

Conclusions: This three phase program employing global assessment of learner need, targeted assessment of clinical reasoning deficit, and direct observation utilizing dynamic coaching and feedback is an effective remediation strategy. The strength of our approach involves the targeted, granular assessment of clinical reasoning deficit and the ability to translate a skillset into practice with standardized direct observation. 

 

Keywords: Remediation; Clinical Reasoning; Coaching; Direct Observation; Targeted Assessment; Global Assessment; Graduate Medical Education; Deliberate Practice

Introduction

Based on a national survey of program directors (PD), it is common for internal medicine (IM) residents to struggle during training.(Yao, 2000) Accurate assessment of the primary area of struggle is critical, yet challenging.(Warburton, Goren and Dine, 2017) Insufficient medical knowledge, inefficient use of time, and poor clinical reasoning, defined as a complex cyclical process of information gathering, information integration and interpretation, working diagnosis formation, and updating prior probabilities as new information is learned with the end goal of sufficiently reducing diagnostic uncertainty, are common deficiencies requiring remediation.(Bowen, 2006) Those who struggle with clinical reasoning do not necessarily lack medical knowledge, but rather the ability to effectively apply knowledge to clinical practice. For example, a learner may know the differential diagnosis for dizziness, and even do well on a standardized exam testing such knowledge with prompts, but is unable to efficiently apply this knowledge to a patient presenting to clinic with chief complaint of dizziness. Assessment of clinical reasoning skills can be particularly difficult in standard clinical situations where evaluation of residents and fellows frequently focuses on factual information, and direct observation of a trainee’s clinical reasoning skills is often limited. Though methods to improve clinical reasoning have been proposed, and there are new established models that elucidate fundamental concepts of clinical reasoning, limited evidence is available to guide remediation practices.(Bowen, 2006)(Guerrasio and Aagaard, 2014)(Marcum, 2012) Using a previously published remediation framework, we sought to identify graduate medical learners struggling with clinical reasoning within the University of Virginia (UVA) Department of Medicine (DOM) (phase 1).(Warburton, Goren and Dine, 2017) Once identified, learners were referred for structured remediation in two subsequent phases. 

Methods

There are 134 residents and 81 fellows within the UVA DOM.  In the fall of 2016, we implemented a three phase remediation program for graduate medical learners within the DOM who struggle with clinical performance. 

 

Phase 1: Learners who are not meeting milestones are referred by the Program Director or the Clinical Competency Committee (CCC) to a remediation specialist (0.4 FTE) who performs a standardized, global assessment and identifies a primary clinical deficit on which to focus the remediation (Figure 1).(Warburton, Goren and Dine, 2017) 

 

Figure 1. An Algorithm for Identification and Referral to a Novel Clinical Reasoning Coaching Program

 

This global assessment includes review of the learner’s file using a standardized checklist, focusing on clinical performance in the current program as assessed by standardized programmatic evaluations, standardized test scores, and examination of the learner’s performance in the prior program. The global assessment also includes direct communication with evaluators, additional direct observation when necessary, and a face-to-face interview with the learner with the end goal of diagnosing a primary deficit in one of the following areas: medical knowledge, clinical reasoning, organization and efficiency, and professionalism.

 

Phase 2: Those identified as having a primary clinical reasoning deficit are referred to a clinical reasoning coach (0.2 FTE) to initiate a novel clinical reasoning remediation program. In contrast to a previously described clinical reasoning remediation program, our session begins with a 10-step, case-based targeted assessment to further delineate the clinical reasoning deficit along the following spectrum: hypothesis generation, data collection; problem representation; illness script knowledge and organization; and appropriate manipulation of the differential diagnosis (Supplement 1).(Guerrasio and Aagaard, 2014) We conduct weekly one-on-one, in-person coaching sessions that include a review of key clinical reasoning terms, cognitive biases/error with debiasing strategies, and dual process reasoning using handouts and online videos. Case-based reasoning exercises are then targeted to the specific clinical reasoning deficit. Utilizing deliberate practice, learners work through segmented clinical reasoning cases and exercises to promote metacognition, using frequent ‘stops’ to determine the reasoning behind their ideas and decisions.(Ericsson, 2004) After the specific clinical reasoning deficit is identified, the coach employs an adapted model that integrates the analytic and non-analytic processes of cognition with metacognition to promote reflection on the reasoning process.(Marcum, 2012) Learns are taught to reason in a hypothesis-driven manner, first forming a broad differential diagnosis based on a chief complaint followed by directed data gathering. Improvement in clinical reasoning skills, assessed by the clinical reasoning coach, is demonstrated by evidence of consistent mental comparison of diagnostic possibilities from the presentation of the chief complaint through plan generation, with constant modification as new information is revealed.

 

Phase 3: Lessons learned through direct coaching are fed forward by the clinical reasoning coach to faculty evaluators for use during subsequent direct observation on scheduled clinical rotations. Armed with data from the global and targeted assessment, the clinical reasoning coach gathers real-time feedback from these clinical rotations in order to coach faculty evaluators, creating a dynamic process of coaching and feedback. Faculty evaluators use a standardized direct observation tool (Supplement 2) to inform the coaching process.  

Results

A comprehensive assessment and individualized remediation plan was developed and implemented for twelve resident and fellow learners (5% of total learners) in the DOM at UVA. Clinical reasoning was the most commonly identified deficit (either primary or secondary), in eight out of fourteen learners. Targeted assessment of these learners by a coach revealed deficits in the following domains of clinical reasoning: hypothesis generation (5/8), data gathering (2/8), problem representation (6/8), illness script knowledge and organization (2/8), or appropriate manipulation of the differential diagnosis (7/8). Phase 2 of remediation was time-intensive, as has been previously reported for clinical reasoning deficits.(Guerrasio, Garrity and Aagaard, 2014) The clinical reasoning coach spent 11 hours of direct observation and 17 hours in preparation, on average, per learner. After implementation of the individualized remediation plans, learner performance, as assessed based on standard residency evaluations and a standardized direct observation tool. All learners are currently in good standing in their respective programs.

Discussion

This unique three phase program, utilizing global assessment, targeted clinical reasoning remediation, and structured direct observation on clinical rotations allows for accurate identification of specific clinical reasoning deficits and individualized instruction to effectively address deficiencies. To our knowledge, we are the first to describe this targeted identification of clinical reasoning deficit to guide coaching. Our study is limited by small sample size at a single institution, and we acknowledge the subjectivity in the clinical reasoning assessment process. However, we feel this systematic approach to remediation of clinical reasoning skills is reproducible at other institutions with appropriate commitment of time and financial resources, and builds on a previously successful clinical reasoning remediation program at another academic center.(Guerrasio and Aagaard, 2014) The strength of our approach involves the ability to translate a skillset into practice with standardized direct observation. Initial targeted coaching provides the framework that augments the subsequent direct observation process already in place at many institutions, and this targeted approach combined with a direct observation tool encourages higher quality feedback. Future directions may include expansion to other clinical departments and comparison of this approach to other forms of coaching. 

Take Home Messages

  • Assessment of clinical reasoning skills is challenging, and limited evidence is available to guide remediation practices.
  • We implemented a three phase remediation program for struggling graduate medical learners.
  • Clinical reasoning was the most commonly identified deficit among struggling learners and targeted assessment revealed problem representation and appropriate manipulation of the differential diagnosis as two common areas of struggle within the clinical reasoning domain. 
  • This three phase program employing global assessment of learner need, targeted assessment of clinical reasoning deficit, and direct observation utilizing dynamic coaching and feedback is an effective remediation strategy.
  • The strength of our approach involves the targeted, granular assessment of clinical reasoning deficit and the ability to translate a skillset into practice with standardized direct observation. 

Notes On Contributors

Dr. Andrew Parsons is an Assitant Professor of Medicine at the University of Virginia (UVA) School of Medicine, where he works as a hospitalist. Dr. Parsons directs the Clinical Skills Course for the School of Medicine and serves as Assistant Program Director and Lead Clinical Reasoning Coach for the UVA Internal Medicine Residency Program. At the GME level, he chairs the Clinical Reasoning Subcommittee, a multidisciplinary group focused on remediation for residents and fellows who struggle with clinical reasoning. 

Dr. Karen Warburton is an Associate Professor of Medicine at the University of Virginia (UVA) School of Medicine, where she works as a transplant nephrologist. Dr. Warburton has 10 years of GME leadership experience, having served as an associate program director of the internal medicine residency and the nephrology training program at the University of Pennsylvania, prior to moving to UVA in 2016. At UVA, she serves as the Director of GME Professional Development in the Department of Medicine and runs a GME-wide coaching and remediation program for residents and fellows who struggle with clinical performance. 

Acknowledgements

This work was previously presented as a poster at the following:

'Clinical Reasoning Coaching for the Medicine Learner in Need'. Alliance for Academic Internal Medicine (AAIM) / Association for Program Directors in Internal Medicine (APDIM) Fall Meeting, October, 2018. Poster Presentation. Authors: Parsons AS, Warburton KM.

'Clinical Reasoning Coaching for the Medicine Learner in Need'. University of Virginia (UVA) Academy of Distinguished Educators (ADE) Medical Education Week, March, 2018. Poster Presentation. Authors: Parsons AS, Warburton KM.

Bibliography/References

Bowen, J. L. (2006) 'Educational Strategies to Promote Clinical Diagnostic Reasoning,' New England Journal of Medicine, 355(21), pp. 2217–2225. https://doi.org/10.1056/NEJMra054782

 

Ericsson, K. A. (2004) 'Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains,' Academic Medicine, 79(Supplement). https://doi.org/10.1097/00001888-200410001-00022

 

Guerrasio, J. and Aagaard, E. M. (2014) 'Methods and Outcomes for the Remediation of Clinical Reasoning,' Journal of General Internal Medicine, 29(12), pp. 1607–1614. https://doi.org/10.1007/s11606-014-2955-1

 

Guerrasio, J., Garrity, M. J. and Aagaard, E. M. (2014) 'Learner Deficits and Academic Outcomes of Medical Students, Residents, Fellows, and Attending Physicians Referred to a Remediation Program, 2006–2012,' Academic Medicine, 89(2), pp. 352–358. https://doi.org/10.1097/ACM.0000000000000122

 

Marcum, J. A. (2012) 'An integrated model of clinical reasoning: dual-process theory of cognition and metacognition,' Journal of Evaluation in Clinical Practice, 18(5), pp. 954–961. https://doi.org/10.1111/j.1365-2753.2012.01900.x

 

Warburton, K. M., Goren, E. and Dine, C. J. (2017) 'Comprehensive Assessment of Struggling Learners Referred to a Graduate Medical Education Remediation Program,' Journal of Graduate Medical Education, 9(6), pp. 763–767. https://doi.org/10.4300/JGME-D-17-00175.1

 

Yao, D. C. (2000) 'National Survey of Internal Medicine Residency Program Directors Regarding Problem Residents,' JAMA, 284(9), p. 1099. https://doi.org/10.1001/jama.284.9.1099

Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

This study was reviewed by the University of Virginia Institutional Review Board and was deemed exempt. Reference number: 2018038400.

External Funding

This paper has not had any External Funding

Reviews

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Joseph Rencic - (31/08/2019)
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This is a valuable paper for programs looking to remediate a difficult but common problem, a clinical reasoning deficit. It provides a practical, step-by-step process for remediating struggling learners. Thus, readers can understand exactly what they need to do to implement such a program in their institution. The intervention may not be generalizable to all institutions because the coaches received significant time to perform their role (0.2 FTE) and the time required for the remediation was significant. However, other institutions who have developed a coaching system for remediation have used volunteer fellows or attendings for this purpose. Their use of Guerrasio et al.'s remediation approach is laudable, as this approach is an evidence-based remediation strategy for dealing with clinical reasoning deficits. Overall, this is an excellent remediation intervention that can benefit any program director or dean looking to develop a remediation program in clinical reasoning at their institution.
Possible Conflict of Interest:

I have collaborated with Dr. Parsons and Dr. Warburton on a paper without relevance to this topic. Dr. Warburton and I presented at a conference together on remediation.

Ken Masters - (12/06/2019) Panel Member Icon
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An interesting paper on a very common problem – the inability of learners to use their learnt medical knowledge as a basis for clinical reasoning.

The paper details the process of identifying the students with clinical reasoning problems and then the remediation. The supporting supplementary files give further details of the very scaffolded approach to guiding the student through the process of reasoning. I particularly like the fact that there are guiding questions, as, so frequently, it is simply the inability to ask the correct questions at the correct time that leads to a failure in clinical reasoning. If students can develop the habit, then, hopefully, it will eventually become an intuitive process.

I am also impressed by the amount of time taken for the individual remediation. I’m not sure how many medical schools would have the resources for this, especially as some schools may have many students requiring this, but that is not a criticism of the paper – teaching good clinical reasoning is not something that can be accomplished by lecture or seminar.

I would like to have seen a little more evaluation data, but, as the paper is presented as a “New education method or tool” rather than a full-blown research paper, the evaluation data presented are sufficient.

Small issue with the paper: There are quite a few small typos and errors in the paper (e.g. “Learns are taught..”), and I think the authors should have taken greater care with the proofing of the manuscript (and the supplementary documents).

A good an useful start, and something that, even at this early stage, could be of value of others – I look forward to seeing a more detailed and robust research paper on the topic.
Possible Conflict of Interest:

For Transparency: I am an Associate Editor of MedEdPublish

Jackcy Jacob - (27/03/2019)
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Remediation of clinical reasoning (CR) is one of the most challenging in the coaching of a learner - both student and resident. Having a framework for discussion that can be shared with the learner helps them to self-assess where their struggles are by breaking down the parts of an otherwise nebulous thought process. I used the 10 step process with a student who was struggling with CR : he and I appreciated being able to use the same jargon and referring back to a particular step when debriefing the presentation of a real patient scenario. There would need to be robust faculty development which orients core faculty to the same jargon and dynamic coaching/feedback techniques.
This a great tool for taking an in depth dive of a complex problem that often leaves students and faculty frustrated. The authors offer a very reasonable and useful, stepwise approach.
Parvathi Perumareddi - (22/03/2019)
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I agree that this is a very important topic in that progress should he monitored not only by in-training exams and clinical evaluations but also via the competencies.
Remediation is indeed critical for deficits but my question would be regarding who the clinical coaches are and also how the direct observation is evaluated and compared to other residents.
This article highlights an important area of residency training worth investigating.
Janae Heath - (15/01/2019)
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This innovative approach to remediation of clinical reasoning highlights an area of critical need for graduate medical learners and educators. Specifically, this paper by Parsons and colleagues highlights a novel three-phase remediation program, consisting of a standardized global assessment and deficit identification, followed by dedicated clinical reasoning coaching for trainees.

A few additions would strengthen the manuscript. First, it would be useful for readers to have additional details of the case-based targeted assessment to allow for replication (specifically, what level of faculty training is required? How were the cases chosen for the 10-step assessment? How was the supplemental handout used in the coaching process? Did the identified clinical reasoning deficit alter the approach to remediation?). Furthermore, while some details were provided on the learner-centered interventions and direct observation exercises, it would be helpful to further elaborate on these, and to discuss the generalizability and the feasibility of similar interventions at other institutions. Finally, similar to prior comments, I agree that more detailed definition of successful remediation would strengthen the manuscript (as was thoroughly explained in response to another comment).

Otherwise, I would be most interested in further discussion on the main differences between this strategy and what was previously published and why the authors perceive this strategy is superior.

Overall, this paper adds an important strategy for remediation of clinical reasoning deficits, and I look forward to the subsequent scholarship by the authors in this area.
Possible Conflict of Interest:

None

Megan Anakin - (10/01/2019) Panel Member Icon
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I read this short article with interest because at my medical school, we are always looking for ways to support and enhance the learning of clinical reasoning for our students whether they are in our undergraduate programme or out working in our local hospitals as junior doctors. I appreciated reading about the three phase coaching programme, however, I would have appreciated more information about the programme, such as how it was evaluated and over what time period learners received support by the coaching programme. The results section is quite brief. In addition to the average time the coach spent with each participant, it would be helpful to know what data were used to support the statement that “All learners are currently in good standing in their respective programs”. Supplement 2 shows a data collection tool but no data collected from it are presented in the results. The take home message about the coaching programme “is an effective remediation strategy” may need to be qualified because in this was intervention study with no comparison group.

As the authors signal that they would like to pursue this line of research, one idea to enhance their efforts might be to consider the theoretical perspective they are adopting to study and support the learning of clinical reasoning. Although not explicitly stated in this article, the language used to describe how learners are challenged to learn clinical reasoning suggest that a deficit perspective has been used, where learners were diagnosed with “Insufficient medical knowledge, inefficient use of time, and poor clinical reasoning”. It is common in educational research to adopt a growth-orientation to interpreting learners’ different learning trajectories. Some learners take longer to develop their understanding of, and ability to coordinate, complex sets of skills, knowledge, and attitudes, like those involved with clinical reasoning, and they may require different modes of learning such as repeated practise and coaching with targeted feedback. Although about the topic of professionalism and not clinical reasoning, an example of an article that demonstrates this theoretical orientation is Cruess RL, Cruess SR, Steinert Y. Amending Miller’s pyramid to include professional identity formation. Academic Medicine. 2016 Feb 1;91(2):180-5.