Amiesha Panchal, MD Clinton Pong, MD Lucia Sommers, MD Peer Group Clinical Reasoning: Problem-Based Journaling (PBJ) & Practice Inquiry (PI) Amiesha Panchal, MD Clinton Pong, MD Lucia Sommers, MD http://bwfamilymedicine.com/

Disclosures None

Agenda On completion of this session, the participants should be able to: Describe two models of peer group clinical reasoning for medical students and faculty PBJ PI Compare and contrast the clinical reasoning process as it relates to level of training and how this impacts session content and style Describe the facilitator skills utilized at different learning levels and how to adapt style to novice, advancing or expert clinicians

Key Concepts Deliberative Practice Bloom’s Taxonomy Action Science: Single-loop, double-loop and triple-loop learning

How do we do this in the clinic? How to become an expert Deliberative Practice In order to become an expert, you need to dedicate 10,000 hours over 10 years Practice involves repeated, well-defined activities. Improvement requires two components: fast and immediate feedback in the moment, followed by slower reflection, deliberation and revision. How do we do this in the clinic? Ericsson, K.A. (2004). Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains. Academic Medicine. 79(10), S70-81.

Expert Diagnostic Practice 3) Reflective integration of the knowledge and stories into a diagnosis 4) Continuous learning through clinical practice and broader admission of uncertainty, humility for development, change and growth Extensive clinical knowledge Skill with patient stories Mylopoulos, M., et al. (2012) Renowned Physicians’ Perceptions of Expert Diagnostic Practice. Acad Med, 87(10), 1413-1417.

Problem-Based Journaling (PBJ) Clinical Reasoning Tasklist & “Q-list”  Daily reflections Weekly journals What do I reflect on? (Level 2 or 3 “Meta-Questions”) How did I help? Where do I fit in? What did I do? Why did I do it? What can I do? What do I know, and how did I come to know it?

Move beyond your knowledge, skills and attitudes and reflect on your metacognition. metacognitive skill-building and strategies (i.e. “when a patient has >3 complaints, it is important to re-prioritize and negotiate a plan on what to cover.”) content-specific knowledge (i.e. “I need to read more”)

Practice Inquiry (PI) Ongoing, small group, practice-based CME activity Enhance clinical judgment Enable practice change Structured discussion of patients that present diagnostic, therapeutic, prognostic, and/or communication challenges

Comparison of Groups Group structure Pre-work Case selection Group expectations PBJ (med students) Group structure -3-4 students, once/week for 4-6 wks -2hr session -mandatory 2. Pre-work -students select a case and write journal entry, written instructions given 3. Case selection -one case/week -students given specific instructions on how to select a case -low volume of pts, no continuity 4. Group expectations -confidentiality PI (Practicing clinicians) 1. Group structure -once/month -1hr session -voluntary -none, could review case in advance -less specific instruction – any dilemma case -”patient that you are stuck on”” -listen without interrupting -respect

Comparison of Groups Process – the case presentation Managing uncertainty Follow up PBJ: The case presentation -facilitator role models – presents own case -students share journal entry, 2-5 min, 5-10 min discussion 2. Managing uncertainty -use of questions in Reflective Cycle to guide journaling -Q list -discussion of hidden curriculum 3. Follow up -students report back the following week

http://www.afs.org/blog/icl/?p=2653 http://markholmgren.com/2014/05/16/becoming-a-learning-organization-part-one/

Comparison of Groups Process – the case presentation Managing uncertainty Follow up PI: The case presentation -START with dilemma statement, then give case details -scribe on board -colleagues ask clarifying questions -inquiry process -reconstruction of dilemma case 2. Managing uncertainty -inputs to clinical judgment 3. Follow up -case log kept -follow up at start of next meeting

Inputs to Judgment

Group Facilitation Practicing clinician MS 3 & 4 MS 1 & 2

Group Facilitation Students Remove focus from inadequacies (over medical knowledge & skills) Guidance in identifying “stuck”points Bring hidden curriculum forward Challenge: lack of continuity  tend to choose inpatient cases

Group Facilitation Residents Rushing & multiple demands  need to prioritize uncertainties Maintain structure to keep discussion fruitful Challenges: burnout, negativity

Group Facilitation Practicing clinicians Very motivated More room for open discussion Challenge: interruptions, not following discussion format

References Argyris, Chris.  (1991). Teaching Smart People How To Learn.  Harvard Business Review.  May-June 1991, pp. 99-109. Ericsson, K.A. (2004). Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains. Academic Medicine. 79(10), S70-81. Mylopoulos, M., et al. (2012) Renowned Physicians’ Perceptions of Expert Diagnostic Practice. Acad Med, 87(10), 1413-1417. Goldszmidt, M., Minda, J.P., Bordage, G. (2013) Developing a Unified List of Physicians' Reasoning Tasks During Clinical Encounters. Acad Med, 88(3), 390-397. Sommers, L.S., et al. (2007). Practice inquiry: Clinical uncertainty as a focus for small- group learning and practice improvement. Journal of General Internal Medicine, 22(2), 246–252. Sommers, L.S., et al. (2013). Clinical Uncertainty in Primary Care, The Challenge of Collaborative Engagement. New York: Springer Science+Business Media.

Other Resources Diagnosis: Management: Reflection: "Checklists to Reduce Diagnostic Errors" "White Coats and Fingerprints - diagnostic reasoning in medicine and investigative methods of fictional detectives" Management: "Q-list manifesto: How to Get Things Right in Generalist Medical Practice" Reflection: "Teaching Smart People How to Learn" "Cognitive debiasing 1: origins of bias and theory of debiasing" "Cognitive debiasing 2: impediments to and strategies for change."

MS3 & 4: Assessment and Plan MS2: Diagnosis MS1 H&P

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