Minding the gap: towards a shared clinical reasoning lexicon across the pre-clerkship/clerkship transition.

Teaching and learning of clinical reasoning are core principles of medical education. However, little guidance exists for faculty leaders to navigate curricular transitions between pre-clerkship and clerkship curricular phases. This study compares how educational leaders in these two phases understand clinical reasoning instruction. Previously reported cross-sectional surveys of pre-clerkship clinical skills course directors, and clerkship leaders were compared. Comparisons focused on perceived importance of a number of core clinical reasoning concepts, barriers to clinical reasoning instruction, level of familiarity across the undergraduate medical curriculum, and inclusion of clinical reasoning instruction in each area of the curriculum. Analyses were performed using the Mann Whitney U test. Both sets of leaders rated lack of curricular time as the largest barrier to teaching clinical reasoning. Clerkship leaders also noted a lack of faculty with skills to teach clinical reasoning concepts as a significant barrier (p < 0.02), while pre-clerkship leaders were more likely to perceive that these concepts were too advanced for their students (p < 0.001). Pre-clerkship leaders reported a higher level of familiarity with the clerkship curriculum than clerkship leaders reported of the pre-clerkship curriculum (p < 0.001). As faculty transition students from the pre-clerkship to the clerkship phase, a shared understanding of what is taught and when, accompanied by successful faculty development, may aid the development of longitudinal, milestone-based clinical reasoning instruction.

Vitiligo Following COVID-19 Vaccination and Primary Infection: A Case Report and Systematic Review.

Vitiligo is an acquired pigmentation disorder with different theorized etiologies, although the exact pathogenesis is still largely unknown. It presents as well-demarcated white plaques throughout the body that result from the loss of melanocytes within the epidermis. Commonly, this condition presents alongside other autoimmune conditions, and it is associated with both genetic and non-genetic factors. We present a patient with no history of autoimmune disease who developed vitiligo after receiving her vaccines against COVID-19. This first occurred within 24 hours of receiving her first vaccine and then worsened after receiving her second vaccine. The depigmented rash was localized to the face, arms, and chest. She was treated with both oral and topical steroids, as well as topical tacrolimus cream. Despite adherence to treatment, the patient only reported subjective improvement in her skin lesions overall. While vitiligo arises sporadically, the temporal relationship between vaccinations and depigmentation makes a stronger case for the vaccine as the inciting factor for this patient, though coincidence is possible. A systematic review of the literature regarding the onset of vitiligo following both infection with and vaccination against COVID-19, this case offers a unique presentation that had a sudden onset and creates a learning opportunity for clinicians to investigate the potential relationship between the receipt of the vaccine and the onset of this skin condition. The goal of this report is to help clinicians be cognizant of the possibility of developing or worsening skin diseases after infection or vaccination so that they can be addressed and treated appropriately.

Perspectives on the current state of pre-clerkship clinical reasoning instruction in United States medical schools: a survey of clinical skills course directors.

OBJECTIVES: Clinical reasoning skills are essential for sound medical decision-making. Though many have suggested that clinical reasoning instruction should begin in pre-clerkship curricula, neither pre-clerkship clinical skills director perspectives nor extent of instruction is known. This survey study serves as part of a needs assessment for United States medical school pre-clerkship clinical reasoning curricula. METHODS: United States medical school pre-clerkship clinical skills course directors were surveyed about perceived importance of formal instruction on clinical reasoning concepts, inclusion of these concepts in the curricula, barriers to instruction, and familiarity with clerkship curricula. Results were analyzed using descriptive and analytic statistics. Narrative comments were analyzed qualitatively for themes. RESULTS: Of 148 directors surveyed, 102 (69%) participated and 89 (60%) completed all closed-ended items. Each clinical reasoning concept was identified as somewhat to extremely important to include in pre-clerkship curricula by 90-99% of respondents. Pre-clerkship curricula included variable degrees of formal instruction for concepts, though most respondents rated their inclusion as moderate or extensive. Perceived importance of teaching most concepts moderately correlated with the degree of inclusion in the curriculum (Spearman's rho 0.39-0.44). Curricular time constraints and lack of faculty with skills to teach these concepts were the most frequently cited barriers to instruction. Respondents indicated being somewhat 57% (n=54) to extremely 29% (n=27) familiar with clerkship curricula at their institutions. CONCLUSIONS: This study is the first to examine pre-clerkship clinical skills course director perspectives about clinical reasoning instruction and extent of its inclusion in their curricula.

A Paraneoplastic Leukemoid Reaction in Primary Lung Sarcoma.

Pulmonary malignancies are known to have high prevalence and mortality. They are associated with different paraneoplastic syndromes, especially pulmonary carcinomas, because they are more common than pulmonary sarcomas. We present a case of a 56-year-old African American male who was admitted to our institution with a three-month history of a dry cough, progressive shortness of breath, and two to three days of right arm swelling. He had extreme leukocytosis (WBC count of 106,500 cells/mm3). Computed tomography (CT) scan of the thorax demonstrated an irregular, thick-walled 14-cm lung mass occupying the middle and upper hemithorax. CT-guided biopsy of the mass confirmed the diagnosis of lung sarcoma.

Dying concerns in young parents with advanced cancer (PWAC): A scoping review.

BACKGROUND: Advanced cancer in young parents (PWAC) can increase dying concerns, the fluctuating thoughts, or feelings, conscious, or unconscious, about an approaching death by a person facing a terminal illness or a family member coping with the impending death of a loved one. However, limited research has been conducted to identify dying concerns in an ill parent as the research has focused on older adults. OBJECTIVE: Our goal was to identify dying concerns that PWAC are expressing and to understand how these concerns affect measurable outcomes. METHOD: CINHAL, MEDLINE, PsychARTICLES, PsycINFO, Social Work Abstracts, Health Source: Nursing/Academic Edition, and Psychology and Behavioral Sciences Collection were searched. Articles included were samples of PWAC, peer-reviewed, and published within the last 10 years. Elderly or pediatric populations, PWAC with adult children, and early-stage cancer were excluded. The initial search resulted in 1,526 articles, 18 were identified as potentially relevant. Fourteen articles were identified and reviewed. RESULTS: PWAC expressed concerns for their children (n = 11), concerns for their co-parent (n = 4), and personal concerns (n = 11). Additionally, PWAC have decreased quality of life, have significant emotional and psychological distress, and have increased family dysfunction in relation to their concerns. Samples limit the generalizability of the findings. Majority of the articles consisted of White, upper, middle-class (n = 8) women (n = 7) diagnosed with breast cancer (n = 11) within nuclear families (n = 11). SIGNIFICANCE OF RESULTS: Dying concerns are described in the literature from a fairly narrow sample of PWAC. Future research should focus on recruiting participants from diverse backgrounds, genders, diagnosis types, and non-nuclear families. Identifying concerns for the co-parent would also add to the understanding of dying concerns.

An HIV Associated Plasmablastic Lymphoma With Spontaneous Tumor Lysis Syndrome.

Plasmablastic lymphoma (PBL) is a rare and aggressive B-cell Non-Hodgkin lymphoma (NHL) associated with immunocompromised states such as HIV. We present a case of PBL in an HIV patient presenting as spontaneous tumor lysis syndrome and discuss the clinical challenges hence encountered.

Diagnosing and Remediating Clinical Reasoning Difficulties: A Faculty Development Workshop.

Introduction: Clinical reasoning is a complex cognitive process that involves multiple steps. Diagnosing and remediating clinical reasoning difficulties requires faculty to have an understanding of the cognitive theory behind clinical reasoning, familiarity with terminology, and a framework to identify different domains of struggle in their learners. Published resources on faculty development to diagnose and remediate clinical reasoning difficulties are limited. We created and implemented a workshop to assist faculty in developing these skills based on the five-domain framework described by Audétat, Laurin, and Sanche. This workshop provides all the materials needed to replicate this training with faculty at other institutions. Methods: The workshop consists of a didactic component and case-based active learning in small groups. Each case focuses on different domains of clinical reasoning difficulties and targets different learner levels (preclinical medical students through residents). The workshop was given in multiple venues in 2016 and 2017. Results: Participants reported the session was valuable (4.71/5.0), the facilitators were effective (4.5/5.0), and the objectives were met (4.28/5.0). They highlighted the strengths of the interactive format, the framework to diagnose and remediate clinical reasoning difficulties, and the excellent take-home resources. They suggested more time for the workshop, revision of cases to better highlight difficulties, and refinement of instructions to approach the cases. These suggestions were incorporated into the current iteration of the workshop. Discussion: We successfully implemented a workshop for diagnosing and remediating clinical reasoning difficulties in multiple venues. The sessions were diverse in terms of faculty participants and learner groups addressed.