Factors associated with clinical reasoning ability

Grubenhoff, Joe Joe.Grubenhoff at CHILDRENSCOLORADO.ORG
Wed Aug 31 15:30:19 UTC 2016


One of these may need a little tweak to include the EM providers. In CAPS below.

If the goal is broader, looking at success in the diagnostic process, there are other key behaviors that are relevant:
            Have I succeeded in making the patient a partner in the diagnostic process?
            Does my patient know when, why, and how to get back to me if the symptoms persist, change or don’t respond to treatment?
                        EM: DOES THE PATIENT UNDERSTAND WHAT TO DO AFTER THEIR ER VISIT IF THE SYMPTOMS PERSIST, CHANGE?
            How often do I personally interact with the radiologists or pathologists interpreting diagnostic tests on my patients?
                        HOW OFTEN DO I CONSULT WITH RAD/PATH BEFORE ORDERING A TEST TO ENSURE IT IS THE CORRECT ONE?
            According to independent surveys, how effectively am I communicating with my patients?
            Do I keep a record of tests and consults ordered and make sure I close the loop on all of these?
            Do I designate a surrogate to review returning test results if I’m going on vacation?

It would be great to hear from others on the listserv about this.  What observable behaviors characterize clinicians who excel at diagnosis?

1)      In the academic setting, providers who tend to use a Socratic approach to draw out their learners’ reasoning are often very adept at diagnosis.

2)      Providers who tend to share their personal stories of erroneous diagnosis AND impart their deconstruction of what led to the error demonstrate an introspection and willingness to serve the success of all by admitting their own “faults”: this underlies a general commitment to improve one’s own dx acumen.

3)      The generalist who, when getting advice from a consultant, is willing to say: “I did not know X,Y,Z. Can you explain this to me so I can catch in the future?”

4)      Along the lines of #3, being willing to tell a patient, I’m not sure what this is and I’m going to look something up. (humility and quest for new knowledge)

a.       As a med student I was seeing a gentleman with AIDS in a VA gen surg clinic with deep purple skin lesions. The surgeon told me to go read up on skin manifestations of AIDS since I admitted I knew nothing. The man had Kaposi sarcomas. I’m now a peds ER doc so never see these but the lesson stayed with me.


[Sig1]
Joe Grubenhoff, MD, MSCS| Associate Professor of Pediatrics
Section of Emergency Medicine | University of Colorado
Children's Hospital Colorado
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From: Mark Graber [mailto:mark.graber at IMPROVEDIAGNOSIS.ORG]
Sent: Wednesday, August 31, 2016 7:38 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Factors associated with clinical reasoning ability

Thanks for sharing Dr Manesh’ survey, Shantanu.

If the goal is to assess their clinical reasoning, I’d like to see other questions, like these:
            When confronted with a new diagnostic challenge, I regularly construct (and document) a differential diagnosis
            When I’m not sure of a diagnosis or ’the next step', I get a second opinion from a peer
            When I’ve reached a tentative diagnosis, I consider whether my conclusion might have been influenced by a cognitive bias

If the goal is broader, looking at success in the diagnostic process, there are other key behaviors that are relevant:
            Have I succeeded in making the patient a partner in the diagnostic process?
            Does my patient know when, why, and how to get back to me if the symptoms persist, change or don’t respond to treatment?
            How often do I personally interact with the radiologists or pathologists interpreting diagnostic tests on my patients?
            According to independent surveys, how effectively am I communicating with my patients?
            Do I keep a record of tests and consults ordered and make sure I close the loop on all of these?
            Do I designate a surrogate to review returning test results if I’m going on vacation?

It would be great to hear from others on the listserv about this.  What observable behaviors characterize clinicians who excel at diagnosis?

Mark


Mark L Graber MD FACP
Senior Fellow, RTI International
Professor Emeritus, SUNY Stony Brook
President, Society to Improve Diagnosis in Medicine




On Aug 30, 2016, at 4:57 PM, Shantanu Nundy <shantanu at HUMANDX.ORG<mailto:shantanu at humandx.org>> wrote:

Colleagues,
Our collaborators at Johns Hopkins will soon be leading a national study to validate the Human Diagnosis Project (Human Dx) open case collaboration platform as a tool for measuring clinical reasoning ability.

Part of this initial study includes surveying physicians and trainees to collect data on factors known or strongly suspected to be associated with clinical reasoning ability, including structural factors (e.g., years of practice, practice setting) and physician attitudes, beliefs, and behaviors.

Dr. Reza Manesh, one of the PIs for the study, copied here, is interested in getting feedback from this group on a late draft of the survey. See attached.

Thank you in advance for your insights,
Shantanu Nundy, MD

--
The Human Diagnosis Project.<http://www.humandx.org/>
One open system.
Created by the global medical community.
For all of humankind.

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<Clinical Quotient Study_Survey_8.30.16.pdf>


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