Background: Preclerkship medical education promotes the concept of clinical certainty through multiple choice testing and diagnostic reasoning curricula focused on System 1 thinking, namely illness scripts and pattern recognition (1). Clerkship medical education reinforces this concept via diagnosis driven didactic sessions and limited physician-led discussions of management uncertainty (2). Yet, clinical uncertainty is an inherent component of medicine and manifests in both diagnosis and management decision-making (3). Hospitalists are in a unique position to educate medical students on the prevalence of clinical uncertainty as well as strategies to mitigate the impact of uncertainty on the accuracy of diagnosis and management.
Purpose: To design and implement a longitudinal, developmental curriculum in clinical uncertainty for preclerkship and clerkship medical students.
Description: The curriculum has three components:1. Following student and faculty workshops focused on diagnostic uncertainty and evidence-based strategies to effectively communicate uncertainty to patients and the clinical care team, we adapted 32 core cases as part of the preclerkship clinical reasoning course to promote iterative diagnosis. 2. For preclerkship students, we implemented a self-directed “Key Clinical Question” activity using a 5-A framework (assess a patient, ask a question, acquire the best evidence, appraise the evidence, apply the evidence to the patient) to promote foundational knowledge on how to design and research a case-based clinical question. 3. We adapted the internal medicine clerkship to include a graded oral presentation, derived from the Fresno Test (4), to assess a student’s ability to identify an area of diagnostic and management uncertainty directly related to their patient’s clinical condition. Students search the literature for a relevant high-quality article and record a 5-8 minute presentation, again using the 5-A framework, where they apply the evidence to the management of their patient. Here we are asking students to apply previous knowledge.During the 2019-2020 academic year, 156 first and second-year medical students completed a two-hour workshop on diagnostic and management uncertainty, individually completed three, 10-minute “Key Clinical Question” presentations to their fellow students, and completed three case-based encounters over 14 months asking them to make a unifying diagnosis. To this point, 99 third-year clerkship students applied their new foundational knowledge in clinical uncertainty to identify a specific area of uncertainty and conduct a presentation based on a real patient encounter. These presentations were reviewed and critiqued by hospitalists.
Conclusions: A multifaceted, hospitalist-led curriculum successfully introduced diagnostic and management uncertainty into the preclerkship case-based curriculum and internal medicine clerkship at our institution. Next steps include a pre and post comparison of course evaluations and student assessment of uncertainty using a validated tolerance for ambiguity score.