Introducing second-year medical students to diagnostic reasoning concepts and skills via a virtual curriculum.

OBJECTIVES: Curriculum for clinical reasoning in the preclinical years is sparse and the COVID-19 pandemic heightened the need for virtual curriculums. METHODS: We developed, implemented and evaluated a virtual curriculum for preclinical students scaffolding key diagnostic reasoning concepts: dual process theory, diagnostic error, problem representation and illness scripts. Fifty-five second-year medical students participated in four 45-min virtual sessions led by one facilitator. RESULTS: The curriculum led to increased perceived understanding and increased confidence in diagnostic reasoning concepts and skills. CONCLUSIONS: The virtual curriculum was effective in introducing diagnostic reasoning and was well-received by second-year medical students.

Teaching Evidence-Based Physical Diagnosis: A Workshop for Hospitalists.

Introduction: Teaching on physical examination, especially evidence-based physical diagnosis, is at times lacking on general medicine rounds. We created a hospitalist faculty workshop on teaching evidence-based physical diagnosis. Methods: The workshop included a systematic approach to teaching evidence-based physical diagnosis, multiple teaching resources, and observed peer teaching. A long-term follow-up session was offered several months after the workshop. Participants completed questionnaires before and after the workshop as well as after the long-term follow-up session. Results: Four workshops were conducted and attended by 28 unique participants. Five hospitalists attended long-term follow-up sessions. Due to the COVID-19 pandemic, repeat sessions and long-term follow-up were limited. In paired analyses compared to preworkshop, respondents after the workshop reported a higher rate of prioritizing ( p = .008), having a systematic approach to ( p < .001), and confidence in ( p = .001) teaching evidence-based physical diagnosis. Compared to before the workshop, participants after the workshop were able to name more resources to inform teaching of evidence-based physical diagnosis ( p < .001). Informal feedback was positive. Respondents noted that the workshop could be improved by allowing more practice of the actual physical exam maneuvers and more observed teaching. Discussion: We created and implemented a workshop to train hospitalists in teaching evidence-based physical diagnosis. This workshop led to improvements in faculty attitudes and teaching skills. Long-term outcomes were limited by low participation due in part to the COVID-19 pandemic.

Multistation Hybrid Adaptation of ABIM MiniCEX for a High Stakes Clinical Examination

Background: The Covid 19 pandemic and the constraints imposed on regulations and safety norms prevented a normal hospital-based clinical examination. The hospitals were closed for students due to the rising number of Covid cases. There was a need to innovate and complete the exit examination as early as possible in a safe environment while ensuring that the outcomes were assessed in a valid and reliable examination process. Description: The Deanery discussed and adapted the ABIM MiniCEX mode into a hybrid, multi-station mode to test the different components. The ABIM MiniCEX form was adopted in parts and used for the different components tested. The stations simulated the real world setting with case scenarios from OP, IP, ER, OT, Field etc. The long case was split into 2-5 stations of seven-fourteen minutes each, and the short cases were of one to two stations. The total time was 28-35 minutes and 14-21 minutes for the long and short cases respectively. The average time per station was seven minutes. The stations were duplicated when required to ensure that the circuit ran without any blocks. The chief examiner, a senior medical educationist, monitored the stations through CC TV, ZOOM, and in person. Outcome: The stations and the outcomes tested were reviewed by the internal and external examiners and the examination board and deemed appropriate. The various MiniCEX stations tested the students' ability to elicit a relevant history, perform a physical examination, present their diagnostic reasoning and discuss the management. Conclusion: The multistation hybrid model of MiniCEX is an efficient method of testing the desired outcomes in a high stakes' clinical examination. It could be a part of the regular examination process in the future.

The diagnostic reasoning involved in interpreting blood results...Part 2

Critical assessment of blood results is pivotal to a patient’s management. Advanced practice involves autonomous consultation and diagnostic reasoning. The field of haematology is often an area that colleagues find daunting. But with a systematic review and analysis of results, differential diagnosis and plans for treatment or referral can be made. This is the second article in a two-part series. The first article in this two-part series examined history taking in patients with suspected haematological disease. This article will discuss common derangement in blood results and the significance relating to patient management, considering latest evidence and guidelines.

Diagnosing Bacterial Infection in the era of Pandemic: A Case Report.

In the coronavirus disease 2019 (COVID-19) pandemic era, physicians' clinical decision-making is often distorted. A man in his 60s presented with an already-subsided cough and anxiety about COVID-19. The physician was influenced by the patient's anxiety and stuck to exclusion of COVID-19. The patient was finally diagnosed with sepsis caused by obstructive pyelonephritis. The key point for diagnosis was physicians' awareness that the patient took slow and heavy steps. To confront the challenge of making an appropriate diagnosis of bacterial infection in the era of COVID-19, physicians should be aware of diagnostic biases and watch patients' general appearance closely.

Integrating a request for assistance model within the East Lothian MSK physiotherapy service

Keywords: eHealth;Musculoskeletal;Service development Purpose: East Lothian Health and Social Care Partnership (ELHSCP) aimed to transform physiotherapy service provision by utilising a Request for Assistance (RFA) model in accordance with the Scottish Government's Active and Independent Living Programme. Technological options including telephone triage were explored to provide this. Development of this service was accelerated due to Covid-19. Aims: 1. Create a single point of access to physiotherapy, with referral to onward services across East Lothian as appropriate. 2. Successfully address people's needs through early intervention and promote self-management. 3. Entrench a patient-focused approach with streamlined processes and pathways. 4. Reduce waiting times for MSK Physiotherapy and GP Practices, saving cost and improving patient experience. Methods: • The MSK Advice Line opened in June 2020 and was based on a RFA service model. • The service was provided by Advanced Physiotherapy Practitioners (APPs) who used advanced critical thinking and expert clinical and diagnostic reasoning skills to facilitate a patient-centred management plan. • Access to the service was made by self-referral. Patients contacted a central number and were offered a telephone assessment. • Following assessment and diagnosis, management options were discussed and decided upon in partnership with the patient. • Due to Covid-19 remote platforms were utilised, with the option of escalation for face to face assessment or onward referral, in line with Government guidelines, as appropriate. • Regular service development huddles were established to ensure consistent service provision across the team and create learning opportunities. • Meetings were arranged with GP Practices in East Lothian to improve communication and build effective working relationships. Results: Over 6000 patients contacted the RFA phoneline • Patient Outcomes: 1. 58% of patients were converted to ongoing physiotherapy treatment, either remotely or face to face. 2. 40% of patient were happy to self-manage and required no further input. 3. 2% of patients were referred onward to other services or did not answer their phone. • A Patient Satisfaction Questionnaire was undertaken: 1. 58% reported the service as excellent. 2. 13% rated it as great. 3. 29% rated it as good. 4. 77% of respondents were happy with remote service. • GP Outcomes 1. High levels of satisfaction among GP Practices was noted. 2. 31% reduction in requests for MRIs from GP Practices in East Lothian since launch. Conclusion(s): Implementation of the MSK Advice Line has demonstrated that the RFA model can be successful in creating a single point of access to physiotherapy services, ensuring patients are successfully directed to the most appropriate service to suit their needs. Evidence shows high levels of patient and GP satisfaction. Suggestions for future work include an ‘online chat’ function to support access routes for the younger population and the ability for APP's to request imaging and onward referral to secondary care. Impact: 1. Reduce physiotherapy waiting time. 2. Improve patient journey. 3. Decrease prescribing and imaging requests, in line with new guidelines. Due to the success of the MSK Advice Line, the RFA model will continue to be a core component of the MSK physiotherapy service and will be rolled out across other services within the ELHSCP. Funding acknowledgements: Not funded.

A Resident Morbidity and Mortality Conference Curriculum to Teach Identification of Cognitive Biases, Errors, and Debiasing Strategies.

Introduction: The morbidity and mortality (M&M) conference has long been a part of the education of residents of all specialties in the United States, yet its structure is variable across training programs. Recent literature has described the use of M&M as a forum for education in quality improvement methodology; however, a structure focusing on education in cognitive biases and errors has not been previously described in MedEdPORTAL. Methods: This structured M&M conference series called upon resident presenters and peers in the audience to examine cognitive biases and errors involved in specific patient cases. Associated materials included preparatory guidelines provided to faculty advisors and resident presenters, a presentation template used during the introductory session, and a handout used during the discussion portions of presentations. Results: During the 2019-2020 academic year, a total of 24 PGY 2 pediatrics residents presented M&M cases. They identified a mean of 3.7 (SD = 1.9) cognitive biases and/or errors per case and a mean of 1.7 (SD = 0.7) debiasing strategies per case. Peers in the audience were also successful in identifying potential biases and errors at play during presentations. Discussion: We found that through this M&M conference structure, residents were able to demonstrate the ability to identify cognitive errors and biases both within themselves and in peers. This provided an effective forum for the identification and discussion of debiasing strategies, even when the series was forced to transition to a virtual format due to the COVID-19 pandemic.

Morning report for all: a qualitative study of disseminating case conferences via podcasting.

BACKGROUND: Despite its long-established importance, diagnostic reasoning (DR) education has suffered uneven implementation in medical education. The Clinical Problem Solvers (CPSolvers) podcast has emerged as a novel strategy to help teach DR through case conferences with expert diagnosticians and trainees. CPSolvers has 25,000 listeners in 147 countries. The aim of this study was to evaluate the podcast by eliciting the developers' goals of the podcast, then determining to what extent they aligned with the listeners' actual usage habits, features they valued, and perceptions of the podcast. METHODS: We conducted semi-structured interviews with 3 developers and 8 listeners from April-May 2020, followed by qualitative thematic analysis. RESULTS: Three major developer goals with sub-goals resulted: 1. To teach diagnostic reasoning in a case-based format by (1a) teaching schemas, (1b) modeling expert diagnostic reasoning, (1c) teaching clinical knowledge, and (1d) teaching diagnostic reasoning terminology. 2. To change the culture of medicine by (2a) promoting diversity, (2b) modeling humility and promoting psychological safety, and (2c) creating a fun, casual way to learn. 3. To democratize the teaching of diagnostic reasoning by leveraging technology. Listeners' usage habits, valued features, and perceptions overall strongly aligned with all these aspects, except for (1c) clinical knowledge, and (1d) diagnostic reasoning terminology. Listeners identified (1a) schemas, and (2c) promotion of psychological safety as the most valuable features of the podcast. CONCLUSION: CPSolvers has been perceived as a highly effective and novel way to disseminate DR education in the form of case conferences, serving as an alternative to traditional in-person case conferences suspended during COVID-19. CPSolvers combines many known benefits of in-person case conferences with a compassionate and entertaining teaching style, plus advantages of the podcasting medium - democratizing morning report for listeners around the world.

Validation of a manual of care plans for people hospitalized with COVID-19.

AIM: Validate a manual of care plans for people hospitalized for coronavirus disease, COVID-19. DESIGN: Validation study with a mixed-method design. METHODS: Design and validation of a care plans manual for people hospitalized by COVID-19. Care plans used standardized languages: NANDA-I, Nursing Outcomes Classification (NOC) and Nursing Intervention Classification (NIC). The design included external and internal validation with quantitative and qualitative analysis. Data collection was between March and June 2020. The study methods were compliant with the Good Reporting of a Mixed Methods Study (GRAMMS) checklist. RESULTS: The manual integrated 24 NANDA-I diagnoses, 34 NOC and 47 NIC different criteria. It was validated by experts of Scientific-Technical Commission, who recommended linking the diagnoses to an assessment. The internal validation validated 17 of 24 diagnoses, 56 of 65 NOC and 86 of the 104 NIC. During the discussion group, 6 new diagnoses proposed were validated and the non-validated diagnoses were linked to the baseline condition of the person.

A Natural Language Processing-Based Virtual Patient Simulator and Intelligent Tutoring System for the Clinical Diagnostic Process: Simulator Development and Case Study.

BACKGROUND: Shortage of human resources, increasing educational costs, and the need to keep social distances in response to the COVID-19 worldwide outbreak have prompted the necessity of clinical training methods designed for distance learning. Virtual patient simulators (VPSs) may partially meet these needs. Natural language processing (NLP) and intelligent tutoring systems (ITSs) may further enhance the educational impact of these simulators. OBJECTIVE: The goal of this study was to develop a VPS for clinical diagnostic reasoning that integrates interaction in natural language and an ITS. We also aimed to provide preliminary results of a short-term learning test administered on undergraduate students after use of the simulator. METHODS: We trained a Siamese long short-term memory network for anamnesis and NLP algorithms combined with Systematized Nomenclature of Medicine (SNOMED) ontology for diagnostic hypothesis generation. The ITS was structured on the concepts of knowledge, assessment, and learner models. To assess short-term learning changes, 15 undergraduate medical students underwent two identical tests, composed of multiple-choice questions, before and after performing a simulation by the virtual simulator. The test was made up of 22 questions; 11 of these were core questions that were specifically designed to evaluate clinical knowledge related to the simulated case. RESULTS: We developed a VPS called Hepius that allows students to gather clinical information from the patient's medical history, physical exam, and investigations and allows them to formulate a differential diagnosis by using natural language. Hepius is also an ITS that provides real-time step-by-step feedback to the student and suggests specific topics the student has to review to fill in potential knowledge gaps. Results from the short-term learning test showed an increase in both mean test score (P<.001) and mean score for core questions (P<.001) when comparing presimulation and postsimulation performance. CONCLUSIONS: By combining ITS and NLP technologies, Hepius may provide medical undergraduate students with a learning tool for training them in diagnostic reasoning. This may be particularly useful in a setting where students have restricted access to clinical wards, as is happening during the COVID-19 pandemic in many countries worldwide.

Malaria in the Time of COVID-19: Do Not Miss the Real Cause of Illness.

We report a case of Plasmodium falciparum malaria in a patient asymptomatically co-infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the current ongoing coronavirus pandemic, co-infections with unrelated life-threatening febrile conditions may pose a particular challenge to clinicians. The current situation increases the risk for cognitive biases in medical management.